1255512687 NPI number — KIMBERLY A SLATTERY CRNA

Table of content: KIMBERLY A SLATTERY CRNA (NPI 1255512687)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255512687 NPI number — KIMBERLY A SLATTERY CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SLATTERY
Provider First Name:
KIMBERLY
Provider Middle Name:
A
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:
1255512687
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/29/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
442 W HIGH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRYAN
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43506-1681
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-636-4517
Provider Business Mailing Address Fax Number:
419-636-6438

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5734 COVENTRY LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46804-7141
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-436-7875
Provider Business Practice Location Address Fax Number:
260-432-9812
Provider Enumeration Date:
11/14/2007

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:  275603 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 367500000X , with the licence number: 4704242032 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: P00477902 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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