1497089684 NPI number — KARLA SHAYNE HOUSEL CRNA

Table of content: KARLA SHAYNE HOUSEL CRNA (NPI 1497089684)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497089684 NPI number — KARLA SHAYNE HOUSEL CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOUSEL
Provider First Name:
KARLA
Provider Middle Name:
SHAYNE
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:
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:
1497089684
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/16/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4135 BOARDMAN CANFIELD RD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
CANFIELD
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44406-9803
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-286-5330
Provider Business Mailing Address Fax Number:
330-286-5396

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
740 E STATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHARON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16146-3328
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-983-7310
Provider Business Practice Location Address Fax Number:
724-983-2797
Provider Enumeration Date:
09/22/2009

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:  RN606176 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 367500000X , with the licence number: RN306266 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 3021867 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000631046 . This is a "ANTHEM BCBS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 164615ZB29 . This is a "MEDICARE PTAN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: P00776761 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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