Healthcare Provider Details

I. General information

NPI: 1376534511
Provider Name (Legal Business Name): KELLY ANDERSON RUPPEL CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELLY ANDERSON SAMOLITIS CRNA

II. Dates (important events)

Enumeration Date: 11/04/2005
Last Update Date: 02/25/2022
Certification Date: 02/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 MATTHEW ST
MARIETTA OH
45750-1635
US

IV. Provider business mailing address

PO BOX 449
MARIETTA OH
45750-0449
US

V. Phone/Fax

Practice location:
  • Phone: 740-376-1994
  • Fax: 740-376-1940
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN.CRNA.05920
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: