Provider Demographics
NPI:1427307065
Name:KELLEY, MISTY D (CRNA)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:D
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:PO BOX 171181
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38187-1181
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1068 CRESTHAVEN RD
Practice Address - Street 2:SUITE 150
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-0800
Practice Address - Country:US
Practice Address - Phone:901-682-2872
Practice Address - Fax:901-682-9316
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN16931367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered