Basic Information
| Provider Information | |||||||||
| NPI: | 1871826735 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DULA | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7757 AUBURN RD STE 15 | ||||||||
| Address2: | |||||||||
| City: | PAINESVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440779604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403500832 | ||||||||
| FaxNumber: | 4403547420 | ||||||||
| Practice Location | |||||||||
| Address1: | 36000 EUCLID AVE | ||||||||
| Address2: | |||||||||
| City: | WILLOUGHBY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440944625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403500832 | ||||||||
| FaxNumber: | 4405790191 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2009 | ||||||||
| LastUpdateDate: | 04/01/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN304555 | OH | N | Nursing Service Providers | Registered Nurse | 367500000X | APRN.CRNA.11083 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 3014866 | 05 | OH | MEDICAID |