Basic Information
Provider Information | |||||||||
NPI: | 1942330626 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KELLY | ||||||||
FirstName: | TERRI | ||||||||
MiddleName: | ELLEN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 3849 | ||||||||
Address2: |   | ||||||||
City: | TERRE HAUTE | ||||||||
State: | IN | ||||||||
PostalCode: | 478030849 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8122348261 | ||||||||
FaxNumber: | 8122348262 | ||||||||
Practice Location | |||||||||
Address1: | 1421 N 7TH ST | ||||||||
Address2: |   | ||||||||
City: | TERRE HAUTE | ||||||||
State: | IN | ||||||||
PostalCode: | 478071005 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8122348261 | ||||||||
FaxNumber: | 8122348262 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/06/2007 | ||||||||
LastUpdateDate: | 03/12/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 28170574A | IN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 000000508494 | 01 | IN | BLUE CROSS/BLUE SHIELD | OTHER | 200853750 | 05 | IN |   | MEDICAID |