Basic Information
| Provider Information | |||||||||
| NPI: | 1194044776 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | LEVI | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1007 KINGS RD | ||||||||
| Address2: | |||||||||
| City: | KIRKSVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 635012627 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 315 S OSTEOPATHY AVE | ||||||||
| Address2: | |||||||||
| City: | KIRKSVILLE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 635016401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6607851098 | ||||||||
| FaxNumber: | 6606650333 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2010 | ||||||||
| LastUpdateDate: | 05/21/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 2005008072 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.