Provider Demographics
NPI:1245481118
Name:DILLER, STACEY D (CRNA)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:D
Last Name:DILLER
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 1:750 CROSS POINTE RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230-6691
Mailing Address - Country:US
Mailing Address - Phone:614-552-0061
Mailing Address - Fax:614-552-0168
Practice Address - Street 1:793 W STATE ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43222-1551
Practice Address - Country:US
Practice Address - Phone:614-552-0061
Practice Address - Fax:614-552-0168
Is Sole Proprietor?:No
Enumeration Date:2008-10-09
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLAPRN11016493367500000X
OHRN300865367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered