Basic Information
| Provider Information | |||||||||
| NPI: | 1477722999 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLEY | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3180 KETTERING BLVD | ||||||||
| Address2: | |||||||||
| City: | MORAINE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454391924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372976072 | ||||||||
| FaxNumber: | 9372930969 | ||||||||
| Practice Location | |||||||||
| Address1: | 375 DIXMYTH AVE | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452202475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138722432 | ||||||||
| FaxNumber: | 5138728857 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2008 | ||||||||
| LastUpdateDate: | 05/13/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN300452 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.