Healthcare Provider Details

I. General information

NPI: 1811394489
Provider Name (Legal Business Name): KATHLEEN M DOUGLASS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2014
Last Update Date: 01/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 E STATE ST
SHARON PA
16146-3328
US

IV. Provider business mailing address

4135 BOARDMAN CANFIELD RD SUITE 101
CANFIELD OH
44406-9803
US

V. Phone/Fax

Practice location:
  • Phone: 724-983-7310
  • Fax: 724-983-2797
Mailing address:
  • Phone: 330-286-5330
  • Fax: 330-286-5396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN610072
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: