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General NPI Number Information
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NPI Number | 1821574310
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Entity Type | Individual
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Provider Name | KELLEY LARSON ETHERIDGE APRN/CRNA
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Gender | Female
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Dates
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Enumeration Date | 07/17/2018
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Last Update Date | 04/16/2025
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Provider Practice Location Address
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Address Line | 195 EASTERN BLVD
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City | GLASTONBURY
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State | CT
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Zip | 06033-4312
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Country | US
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Telephone | 860-667-9542
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Fax |
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Provider Business Mailing Address
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Address Line | 88 BLACK WALNUT DR
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City | DURHAM
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State | CT
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Zip | 06422-1400
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Country | US
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Telephone | 860-575-2052
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | 7675
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License Number State | CT
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