Provider Demographics
NPI:1164438834
Name:GERLACH, MICKI L (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:MICKI
Middle Name:L
Last Name:GERLACH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 636256
Mailing Address - Street 2:CENTRAL CREDENTIALING
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6256
Mailing Address - Country:US
Mailing Address - Phone:513-585-5502
Mailing Address - Fax:513-585-5511
Practice Address - Street 1:800 ROSE ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-2364
Practice Address - Country:US
Practice Address - Phone:859-323-5956
Practice Address - Fax:859-323-1080
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3016780367500000X
OHCOA 08742 NA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200832390Medicaid
KY7100011430Medicaid
OH2636919Medicaid
KY7100011430Medicaid