Healthcare Provider Details

I. General information

NPI: 1841830916
Provider Name (Legal Business Name): STACIE RENEE KOBYLANSKI CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2020
Last Update Date: 01/07/2020
Certification Date: 01/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4665 DOUGLAS CIR NW STE 100
CANTON OH
44718-3673
US

IV. Provider business mailing address

88 WILLOW DR
BOARDMAN OH
44512-2109
US

V. Phone/Fax

Practice location:
  • Phone: 330-499-5700
  • Fax: 330-498-4229
Mailing address:
  • Phone: 330-501-5130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number127185
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: