Provider Demographics
NPI:1780870113
Name:DEETER, KELLIE L (CRNA)
Entity type:Individual
Prefix:MS
First Name:KELLIE
Middle Name:L
Last Name:DEETER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:L
Other - Last Name:WINSLOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN CRNA, CNP
Mailing Address - Street 1:1171 PIONEER PASS
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:NORWALK
Mailing Address - State:OH
Mailing Address - Zip Code:44857-8928
Mailing Address - Country:US
Mailing Address - Phone:419-706-4150
Mailing Address - Fax:419-964-5480
Practice Address - Street 1:1171 PIONEER PASS
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:OH
Practice Address - Zip Code:44857-8928
Practice Address - Country:US
Practice Address - Phone:419-706-4150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-19
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLE-00027692363LA2200X
OH09618367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2810980Medicaid