Basic Information
| Provider Information | |||||||||
| NPI: | 1497073761 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEINE | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
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| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KEGLEY | ||||||||
| OtherFirstName: | KELLY | ||||||||
| OtherMiddleName: | A | ||||||||
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| OtherCredential: | CRNA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1988 | ||||||||
| Address2: | |||||||||
| City: | COUNCIL BLUFFS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 515021988 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7123225565 | ||||||||
| FaxNumber: | 7123225566 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 RIDGE ST | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | COUNCIL BLUFFS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 515034643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7123225565 | ||||||||
| FaxNumber: | 7123225566 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2010 | ||||||||
| LastUpdateDate: | 05/21/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 62406 | NE | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.