Healthcare Provider Details

I. General information

NPI: 1235706953
Provider Name (Legal Business Name): KELLY JEAN MARTIN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2021
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7101 JAHNKE RD
RICHMOND VA
23225-4017
US

IV. Provider business mailing address

PO BOX 840853
DALLAS TX
75284-0853
US

V. Phone/Fax

Practice location:
  • Phone: 804-483-0745
  • Fax:
Mailing address:
  • Phone: 972-233-1999
  • Fax: 972-233-3666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number133715
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0024188172
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1046794
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: