Provider Demographics
NPI:1740237049
Name:ELLO, SUSAN (CRNA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:ELLO
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 1:2409 CHERRY ST
Mailing Address - Street 2:# 305
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43608
Mailing Address - Country:US
Mailing Address - Phone:419-251-3740
Mailing Address - Fax:419-251-3859
Practice Address - Street 1:2213 CHERRY ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43608
Practice Address - Country:US
Practice Address - Phone:419-251-3232
Practice Address - Fax:419-251-3859
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH151065174400000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0756329Medicaid
OH430008616Medicare PIN
OH8203891Medicare ID - Type Unspecified
OH0756329Medicaid
OH8203892Medicare PIN