MEDICARE: DAVID K KELLY CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	ARNP2572842	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G2004Y	OTHER	FL	BCBS

General Provider Information

NPI Number	:	1396736328
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID K KELLY CRNA

Provider Business Mailing Address
First Line	:	291 SOUTHHALL LN
Second Line	:
City	:	MAITLAND
State	:	FL
Zip	:	32751-7274
Country	:	US
Telephone Number	:	407-667-0444
Fax Number	:	407-667-4338

Provider Business Practice Location Address
First Line	:	401 PALMETTO ST
Second Line	:
City	:	NEW SMYRNA BEACH
State	:	FL
Zip	:	32168-7322
Country	:	US
Telephone Number	:	407-667-0444
Fax Number	:	407-667-4338

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/31/2005
Last Update Date	:	07/08/2007

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Directions to “ DAVID K KELLY CRNA” Practice Location

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