Healthcare Provider Details

I. General information

NPI: 1801290911
Provider Name (Legal Business Name): LILA GRAULTY CNRA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2014
Last Update Date: 11/01/2022
Certification Date: 11/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL PARK
WHEELING WV
26003-6379
US

IV. Provider business mailing address

549 CENTER CHURCH RD
CANONSBURG PA
15317-3528
US

V. Phone/Fax

Practice location:
  • Phone: 304-243-3343
  • Fax:
Mailing address:
  • Phone: 412-628-4489
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number018795
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: