Provider Demographics
NPI:1871826735
Name:DULA, KELLY S (CRNA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:S
Last Name:DULA
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 1:36000 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-4625
Practice Address - Country:US
Practice Address - Phone:440-350-0832
Practice Address - Fax:440-579-0191
Is Sole Proprietor?:No
Enumeration Date:2009-09-10
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN304555163W00000X
OHAPRN.CRNA.11083367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3014866Medicaid