Provider Demographics
NPI:1376545202
Name:CUNNINGHAM, KENNETH MICHAEL (CRNA)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:MICHAEL
Last Name:CUNNINGHAM
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13523 BARRETT PARKWAY DRIVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63021-3802
Mailing Address - Country:US
Mailing Address - Phone:636-938-6868
Mailing Address - Fax:636-938-1486
Practice Address - Street 1:5319 HOAG DRIVE
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-1494
Practice Address - Country:US
Practice Address - Phone:440-930-6050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH150955367500000X
OHRN-150955367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0816086Medicaid
OH0816086Medicaid