Provider Demographics
NPI:1336192376
Name:SUMMERLIN- GRADY, DOROTHY LEE (CRNA)
Entity Type:Individual
Prefix:
First Name:DOROTHY
Middle Name:LEE
Last Name:SUMMERLIN- GRADY
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 1:5955 CLAYBOURNE DR
Mailing Address - Street 2:
Mailing Address - City:BARGERSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46106-8391
Mailing Address - Country:US
Mailing Address - Phone:317-966-5576
Mailing Address - Fax:
Practice Address - Street 1:8051 S EMERSON AVE STE 150
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-8635
Practice Address - Country:US
Practice Address - Phone:317-865-2955
Practice Address - Fax:317-865-2954
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH303499367500000X
IN28151003C367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200425840Medicaid
OH2436813Medicaid
OH2436813Medicaid