Provider Demographics
NPI:1366440281
Name:KIRKWOOD, SUSAN (CRNA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:KIRKWOOD
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 1:317 N ENGLISH ST
Mailing Address - Street 2:
Mailing Address - City:LEITCHFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42754-2228
Mailing Address - Country:US
Mailing Address - Phone:502-550-4164
Mailing Address - Fax:
Practice Address - Street 1:317 N ENGLISH ST
Practice Address - Street 2:
Practice Address - City:LEITCHFIELD
Practice Address - State:KY
Practice Address - Zip Code:42754-2228
Practice Address - Country:US
Practice Address - Phone:502-550-4164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH295272367500000X
KY1048153 2125A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100004550Medicaid
000000669363OtherANTHEM
IN200487620Medicaid
OH2491049Medicaid
IN412840118OtherMEDICARE
611077369 1295716850OtherHEALTHNET
P00870718Medicare PIN
$$$$$$$$$00OtherBUREAU OF WORKERS COMP
IN200487620Medicaid
OHKI8233382Medicare ID - Type Unspecified
KY7100004550Medicaid