Basic Information
| Provider Information | |||||||||
| NPI: | 1336192376 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUMMERLIN- GRADY | ||||||||
| FirstName: | DOROTHY | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5955 CLAYBOURNE DR | ||||||||
| Address2: | |||||||||
| City: | BARGERSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461068391 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179665576 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3000 MACK RD | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450145335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5136723309 | ||||||||
| FaxNumber: | 5136723323 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 01/10/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 303499 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 200425840 | 05 | IN | MEDICAID | 2436813 | 05 | OH | MEDICAID |