Basic Information
| Provider Information | |||||||||
| NPI: | 1902208085 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KELLEY GARDNER CRNA, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4518 | ||||||||
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| City: | STATELINE | ||||||||
| State: | NV | ||||||||
| PostalCode: | 894494518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8666403005 | ||||||||
| FaxNumber: | 8666403006 | ||||||||
| Practice Location | |||||||||
| Address1: | 7500 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958235403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164236019 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2014 | ||||||||
| LastUpdateDate: | 09/21/2014 | ||||||||
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| AuthorizedOfficialLastName: | GARDNER | ||||||||
| AuthorizedOfficialFirstName: | KELLEY | ||||||||
| AuthorizedOfficialMiddleName: | RHENE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRINCIPLE | ||||||||
| AuthorizedOfficialTelephone: | 2082860137 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 2120 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.