MEDICARE: KELLY ANN PETERS 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	46429	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	8059UU	OTHER	TX	BLUE CROSS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	88678C	OTHER	TX	BC/BS

General Provider Information

NPI Number	:	1710960117
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY ANN PETERS CRNA

Provider Business Mailing Address
First Line	:	PO BOX 844658
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75284-4658
Country	:	US
Telephone Number	:	800-994-0371
Fax Number	:	254-215-9722

Provider Business Practice Location Address
First Line	:	810 W HIGHWAY 71
Second Line	:
City	:	MARBLE FALLS
State	:	TX
Zip	:	78654-8602
Country	:	US
Telephone Number	:	830-201-8000
Fax Number	:	830-201-8008

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

Provider Enumeration Date	:	11/21/2005
Last Update Date	:	10/13/2025

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