Basic Information
| Provider Information | |||||||||
| NPI: | 1194192476 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CERUTTI | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | MICHELE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ANP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NORWOOD | ||||||||
| OtherFirstName: | KELLY | ||||||||
| OtherMiddleName: | MICHELE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | CVS MINUTECLINIC #09300 | ||||||||
| Address2: | 925 CALIFORNIA AVENUE | ||||||||
| City: | WAHIAWA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 96786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8086217772 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 925 CALIFORNIA AVENUE | ||||||||
| Address2: | CVS MINUTECLINIC #09300 | ||||||||
| City: | WAHIAWA | ||||||||
| State: | HI | ||||||||
| PostalCode: | 96786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8086217772 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2015 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 104121 | AK | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 22569 | AK | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 2300 | HI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.