Provider Demographics
NPI:1447638994
Name:TAVELLI, KELLY JOCELYN (CRNA)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:JOCELYN
Last Name:TAVELLI
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MISS
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:BRICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 13008
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48901-3008
Mailing Address - Country:US
Mailing Address - Phone:505-453-1060
Mailing Address - Fax:
Practice Address - Street 1:1210 W SAGINAW ST
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48915-1927
Practice Address - Country:US
Practice Address - Phone:517-364-6212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-15
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704294056367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered