Healthcare Provider Details

I. General information

NPI: 1841566809
Provider Name (Legal Business Name): KELLIE ANN CUNNINGHAM CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2012
Last Update Date: 04/12/2021
Certification Date: 04/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 MERCY DR NW
CANTON OH
44708-2614
US

IV. Provider business mailing address

4450 BELDEN VILLAGE ST NW STE 307
CANTON OH
44718-2592
US

V. Phone/Fax

Practice location:
  • Phone: 330-489-1000
  • Fax: 330-498-4229
Mailing address:
  • Phone: 330-499-5700
  • Fax: 330-498-4229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCOA.13235-NA
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: