Healthcare Provider Details

I. General information

NPI: 1235417320
Provider Name (Legal Business Name): KELLY MUKTI FLYNN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY M OLSEN CRNA

II. Dates (important events)

Enumeration Date: 07/24/2011
Last Update Date: 05/15/2025
Certification Date: 05/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 E DIVISION ST
FOND DU LAC WI
54935-4560
US

IV. Provider business mailing address

3301 W FOREST HOME AVE
MILWAUKEE WI
53215-2843
US

V. Phone/Fax

Practice location:
  • Phone: 920-929-2300
  • Fax:
Mailing address:
  • Phone: 920-303-8700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number7895
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: