Provider Demographics
NPI:1396089157
Name:MIS, KELLY JEAN (CRNA)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:JEAN
Last Name:MIS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1726 SHERIDAN AVE
Mailing Address - Street 2:
Mailing Address - City:WHITING
Mailing Address - State:IN
Mailing Address - Zip Code:46394-1729
Mailing Address - Country:US
Mailing Address - Phone:219-218-6730
Mailing Address - Fax:
Practice Address - Street 1:5454 HOHMAN AVE
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:IN
Practice Address - Zip Code:46320-1931
Practice Address - Country:US
Practice Address - Phone:219-932-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-19
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28151162A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered