Provider Demographics
NPI:1366535874
Name:KELLEY, CHRYSTAL (CRNA)
Entity type:Individual
Prefix:
First Name:CHRYSTAL
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 235022
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36123-5022
Mailing Address - Country:US
Mailing Address - Phone:334-386-2053
Mailing Address - Fax:334-244-1830
Practice Address - Street 1:2301 SOUTH LAMAR BLVD.
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-6002
Practice Address - Country:US
Practice Address - Phone:662-232-8100
Practice Address - Fax:334-244-1830
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR863288367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS99999Medicare UPIN