Healthcare Provider Details

I. General information

NPI: 1023474012
Provider Name (Legal Business Name): AMANDA G GILLIS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA GILLIS CRNA

II. Dates (important events)

Enumeration Date: 01/07/2016
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 MERCY DR NW
CANTON OH
44708-2614
US

IV. Provider business mailing address

9500 EUCLID AVE # E30
CLEVELAND OH
44195-0001
US

V. Phone/Fax

Practice location:
  • Phone: 330-489-1000
  • Fax:
Mailing address:
  • Phone: 216-444-8986
  • Fax: 216-636-2043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN.CRNA.18613
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: