Provider Demographics
NPI:1962718908
Name:MCDANIEL, KELLY MICHELLE (CRNA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MICHELLE
Last Name:MCDANIEL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:GREER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:632 N 12TH ST # 230
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:KY
Mailing Address - Zip Code:42071-1651
Mailing Address - Country:US
Mailing Address - Phone:270-627-0150
Mailing Address - Fax:
Practice Address - Street 1:632 N 12TH ST # 230
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:KY
Practice Address - Zip Code:42071-1651
Practice Address - Country:US
Practice Address - Phone:270-627-0150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-27
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3006605367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK014650Medicare Oscar/Certification