Provider Demographics
NPI:1427617299
Name:CLUBB, KELLY JEAN (CRNA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JEAN
Last Name:CLUBB
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 1:963 POINSETTIA DR
Mailing Address - Street 2:
Mailing Address - City:CHULUOTA
Mailing Address - State:FL
Mailing Address - Zip Code:32766-9336
Mailing Address - Country:US
Mailing Address - Phone:407-451-4531
Mailing Address - Fax:
Practice Address - Street 1:509 BILTMORE AVE
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28801-4601
Practice Address - Country:US
Practice Address - Phone:828-213-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-06
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9369545367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered