Provider Demographics
NPI:1598848814
Name:GRULY, TINA MARIE (CRNA)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:GRULY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7757 AUBURN RD STE 15
Mailing Address - Street 2:
Mailing Address - City:PAINESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44077-9604
Mailing Address - Country:US
Mailing Address - Phone:440-350-0832
Mailing Address - Fax:440-354-7420
Practice Address - Street 1:7757 AUBURN RD STE 15
Practice Address - Street 2:
Practice Address - City:PAINESVILLE
Practice Address - State:OH
Practice Address - Zip Code:44077-9604
Practice Address - Country:US
Practice Address - Phone:440-350-0832
Practice Address - Fax:440-354-7420
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN285691367500000X
OHAPRN.CRNA.09086367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHRN285691OtherOHIO BOARD OF NURSING