Basic Information
| Provider Information | |||||||||
| NPI: | 1255512687 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SLATTERY | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 442 W HIGH ST | ||||||||
| Address2: | |||||||||
| City: | BRYAN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435061681 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196364517 | ||||||||
| FaxNumber: | 4196366438 | ||||||||
| Practice Location | |||||||||
| Address1: | 5734 COVENTRY LN | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468047141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604367875 | ||||||||
| FaxNumber: | 2604329812 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2007 | ||||||||
| LastUpdateDate: | 06/29/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 275603 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 4704242032 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | P00477902 | 01 | OH | MEDICARE RAILROAD | OTHER |