Provider Demographics
NPI:1437621091
Name:BLACK, KELLY NICOLE (MSN, CRNA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:NICOLE
Last Name:BLACK
Suffix:
Gender:F
Credentials:MSN, CRNA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:NICOLE
Other - Last Name:BERNATCHEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BSN, RN
Mailing Address - Street 1:5687 WILSON MILLS RD
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44143-3208
Mailing Address - Country:US
Mailing Address - Phone:440-391-2478
Mailing Address - Fax:
Practice Address - Street 1:11100 EUCLID AVE
Practice Address - Street 2:ANESTHESIA DEPT
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-5007
Practice Address - Country:US
Practice Address - Phone:216-844-7330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-20
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH123239367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered