Provider Demographics
NPI:1427148683
Name:KELLY, PETER JAMES (CRNA)
Entity type:Individual
Prefix:MR
First Name:PETER
Middle Name:JAMES
Last Name:KELLY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 BUTTONWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-5613
Mailing Address - Country:US
Mailing Address - Phone:203-294-9833
Mailing Address - Fax:
Practice Address - Street 1:391 BROAD ST
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-5844
Practice Address - Country:US
Practice Address - Phone:203-238-1555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTE34306163W00000X
CT000196367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT430000104Medicaid
CT430000104Medicaid