1699757906 NPI number — MS. KELLY CATHERINE DEFEO CRNA , APRN, PHD

Table of content: MS. KELLY CATHERINE DEFEO CRNA , APRN, PHD (NPI 1699757906)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699757906 NPI number — MS. KELLY CATHERINE DEFEO CRNA , APRN, PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEFEO
Provider First Name:
KELLY
Provider Middle Name:
CATHERINE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
CRNA , APRN, PHD
Provider Gender Code:
F

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:
1699757906
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/08/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 125
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CENTER CONWAY
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03813-0125
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-730-5356
Provider Business Mailing Address Fax Number:
603-730-5477

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15 US RTE 302
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLEN
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03838-6300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-730-5356
Provider Business Practice Location Address Fax Number:
603-730-5477
Provider Enumeration Date:
11/14/2005

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:  047170-23-11 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 04717023 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 30342118 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".




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