Provider Demographics
NPI:1487652301
Name:DUTRO, BETH EILEEN SHEPARD (CRNA)
Entity Type:Individual
Prefix:MS
First Name:BETH
Middle Name:EILEEN SHEPARD
Last Name:DUTRO
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 932759
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-0015
Mailing Address - Country:US
Mailing Address - Phone:937-293-8228
Mailing Address - Fax:937-293-8229
Practice Address - Street 1:3535 SOUTHERN BLVD
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1221
Practice Address - Country:US
Practice Address - Phone:937-293-8228
Practice Address - Fax:937-293-8229
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CRNA.02487367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH430039229OtherRAILROAD MEDICARE
OH0807032Medicaid
OH0807032Medicaid