Provider Demographics
NPI:1457453326
Name:KELLY, KIM H (CRNA)
Entity type:Individual
Prefix:MS
First Name:KIM
Middle Name:H
Last Name:KELLY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:H
Other - Last Name:TURNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:111 S FRONT ST
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17101-2010
Mailing Address - Country:US
Mailing Address - Phone:717-782-3282
Mailing Address - Fax:717-231-8964
Practice Address - Street 1:111 S FRONT ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17101-2010
Practice Address - Country:US
Practice Address - Phone:717-782-3282
Practice Address - Fax:717-231-8964
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN213308L367500000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001866520Medicaid
S63084Medicare UPIN
50059758OtherBLUE CROSS KEYSTONE
PARN213308LOtherLICENSE
531019Medicare PIN