MEDICARE: KELLY NICOLE BLACK MSN, CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	123239	OH

General Provider Information

NPI Number	:	1437621091
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY NICOLE BLACK MSN, CRNA

Provider Business Mailing Address
First Line	:	5687 WILSON MILLS RD
Second Line	:
City	:	HIGHLAND HTS
State	:	OH
Zip	:	44143-3208
Country	:	US
Telephone Number	:	440-391-2478
Fax Number	:

Provider Business Practice Location Address
First Line	:	11100 EUCLID AVE
Second Line	:	ANESTHESIA DEPT
City	:	CLEVELAND
State	:	OH
Zip	:	44106-5007
Country	:	US
Telephone Number	:	216-844-7330
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/20/2018
Last Update Date	:	12/20/2018

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