Provider Demographics
NPI:1508979287
Name:O'LEARY, KATHLEEN MARY (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:MARY
Last Name:O'LEARY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:M
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3333 EVERGREEN DR NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9756
Mailing Address - Country:US
Mailing Address - Phone:616-364-4200
Mailing Address - Fax:616-364-7347
Practice Address - Street 1:3333 EVERGREEN DR NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9756
Practice Address - Country:US
Practice Address - Phone:616-364-4200
Practice Address - Fax:616-364-7347
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704139954367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4554876Medicaid
MI4554876Medicaid
MIM73860-026Medicare PIN
MIMI4607-109Medicare PIN