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General NPI Number Information
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NPI Number | 1831498302
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Entity Type | Individual
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Provider Name | JUSTIN PATRICK KELLEY CRNA
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Gender | Male
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Dates
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Enumeration Date | 03/22/2011
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Last Update Date | 03/22/2011
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Provider Practice Location Address
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Address Line | 615 N BONITA AVE
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City | PANAMA CITY
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State | FL
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Zip | 32401-3623
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Country | US
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Telephone | 850-747-6050
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Fax |
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Provider Business Mailing Address
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Address Line | 103 BID A WEE CT
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City | PANAMA CITY BEACH
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State | FL
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Zip | 32413-2784
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Country | US
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Telephone | 334-354-5698
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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 | ARNP 9277209
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License Number State | FL
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