Provider Demographics
NPI:1376534511
Name:RUPPEL, KELLY ANDERSON (CRNA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANDERSON
Last Name:RUPPEL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANDERSON
Other - Last Name:SAMOLITIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 449
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-0449
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 MATTHEW ST
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-1635
Practice Address - Country:US
Practice Address - Phone:740-376-1994
Practice Address - Fax:740-376-1940
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-04
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CRNA.05920367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2207605Medicaid
OH2207605Medicaid
OHP00703829OtherRRMCR
OH3810007682Medicaid
OH8227685Medicare UPIN