1619906336 NPI number — JAMES J KELLEN CRNA

Table of content: JAMES J KELLEN CRNA (NPI 1619906336)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619906336 NPI number — JAMES J KELLEN CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLEN
Provider First Name:
JAMES
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619906336
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/21/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 HAWKINS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IOWA CITY
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52242-1009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-356-2633
Provider Business Mailing Address Fax Number:
319-356-2940

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 HAWKINS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IOWA CITY
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52242-1009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-356-2633
Provider Business Practice Location Address Fax Number:
319-356-2940
Provider Enumeration Date:
07/03/2006

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:  R030050 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: D078551 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0005855 . This is a "BLUE CROSS OF SD" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 753S5KE . This is a "MN BLUE CROSS BS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 5753682 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0573923 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9219547 . This is a "DAKOTACARE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 460224743-48 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5753680 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 796114600 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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