Provider Demographics
NPI:1528028669
Name:EVANS, KELLEY NOELLE (CRNA)
Entity type:Individual
Prefix:MRS
First Name:KELLEY
Middle Name:NOELLE
Last Name:EVANS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KELLEY
Other - Middle Name:NOELLE CRAPPS
Other - Last Name:HERSEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:2435 FOREST DRIVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204
Practice Address - Country:US
Practice Address - Phone:803-454-2613
Practice Address - Fax:803-765-1732
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1332367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAN1052Medicaid
SCQ32656Medicare UPIN
SCAN1052Medicaid