Provider Demographics
NPI:1770556391
Name:BOLAND, KELLY K (CRNA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:K
Last Name:BOLAND
Suffix:
Gender:
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:ONE GI CREDENTIALING DEPARTMENT
Mailing Address - Street 2:PO BOX 381468
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38183-1468
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9614 OLD JOHNNYCAKE RIDGE RD
Practice Address - Street 2:
Practice Address - City:CONCORD TOWNSHIP
Practice Address - State:OH
Practice Address - Zip Code:44060-6521
Practice Address - Country:US
Practice Address - Phone:440-205-1225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH048765367500000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2181491Medicaid
OHBO8226057OtherOHIO MEDICARE NUMBER
AZP00024551OtherTRIWEST
OH2181491Medicaid
OH2181491Medicaid
AZP00024551OtherTRIWEST