Provider Demographics
NPI:1487789954
Name:THOMPSON, KELLY P (CRNA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:P
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:P
Other - Last Name:PORTERFIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5395 FIRETHORN PT
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34609-9511
Mailing Address - Country:US
Mailing Address - Phone:352-597-6082
Mailing Address - Fax:352-597-6078
Practice Address - Street 1:11375 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-5409
Practice Address - Country:US
Practice Address - Phone:352-592-2121
Practice Address - Fax:352-597-6078
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2015-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN1954032367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003404100Medicaid
FLAC855ZMedicare UPIN