Basic Information
| Provider Information | |||||||||
| NPI: | 1982635116 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KNOLLMANN | ||||||||
| FirstName: | KELLY | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 291264 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372291264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9136424900 | ||||||||
| FaxNumber: | 9133810979 | ||||||||
| Practice Location | |||||||||
| Address1: | 2710 RIFE MEDICAL LN | ||||||||
| Address2: | |||||||||
| City: | ROGERS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727581452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4793388000 | ||||||||
| FaxNumber: | 9133810979 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 06/09/2017 | ||||||||
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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 | 163W00000X | C01545 | AR | N | Nursing Service Providers | Registered Nurse | 367500000X | C01545 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 5Y795 | 01 | AR | BCBS OF ARKANSAS | OTHER |