Provider Demographics
NPI:1699757906
Name:DEFEO, KELLY CATHERINE (CRNA , APRN, PHD)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:CATHERINE
Last Name:DEFEO
Suffix:
Gender:
Credentials:CRNA , APRN, PHD
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 125
Mailing Address - Street 2:
Mailing Address - City:CENTER CONWAY
Mailing Address - State:NH
Mailing Address - Zip Code:03813-0125
Mailing Address - Country:US
Mailing Address - Phone:603-730-5356
Mailing Address - Fax:603-730-5477
Practice Address - Street 1:15 US RTE 302
Practice Address - Street 2:
Practice Address - City:GLEN
Practice Address - State:NH
Practice Address - Zip Code:03838-6300
Practice Address - Country:US
Practice Address - Phone:603-730-5356
Practice Address - Fax:603-730-5477
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-14
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH047170-23-11367500000X
NH04717023363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30342118Medicaid
NHRE5593Medicare ID - Type UnspecifiedCRNA