Basic Information
| Provider Information | |||||||||
| NPI: | 1730409681 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUNLEVY | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | KAY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WILFONG | ||||||||
| OtherFirstName: | MICHELLE | ||||||||
| OtherMiddleName: | K. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CRNA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2951 MAPLE AVE | ||||||||
| Address2: | |||||||||
| City: | ZANESVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404554937 | ||||||||
| FaxNumber: | 7404554931 | ||||||||
| Practice Location | |||||||||
| Address1: | 2951 MAPLE AVE | ||||||||
| Address2: | |||||||||
| City: | ZANESVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404554937 | ||||||||
| FaxNumber: | 7404554931 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2010 | ||||||||
| LastUpdateDate: | 02/01/2012 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN.290639-COA1 | OH | N | Nursing Service Providers | Registered Nurse | 163W00000X | RN290639 | OH | N | Nursing Service Providers | Registered Nurse | 367500000X | COA 11855-NA | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 3094548 | 05 | OH | MEDICAID |