1073596680 NPI number — DIANNA LYNN KELLY CRNA

Table of content: DIANNA LYNN KELLY CRNA (NPI 1073596680)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073596680 NPI number — DIANNA LYNN KELLY CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLY
Provider First Name:
DIANNA
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MCCANDLESS
Provider Other First Name:
DIANNA
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRNA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1073596680
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/15/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11781 LEE JACKSON MEMORIAL HWY
Provider Second Line Business Mailing Address:
SUITE 550
Provider Business Mailing Address City Name:
FAIRFAX
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22033-3309
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
571-777-5102
Provider Business Mailing Address Fax Number:
703-563-6256

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 FAIRFIELD DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SENECA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16346-2130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-676-7600
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/29/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  RN185221L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1015493830001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0015509530025 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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