Provider Demographics
NPI:1992754642
Name:MICKLEY, STEPHANIE (CRNA)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:MICKLEY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 N UNION ST
Mailing Address - Street 2:STE 104
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44304-1369
Mailing Address - Country:US
Mailing Address - Phone:330-253-9145
Mailing Address - Fax:330-253-6222
Practice Address - Street 1:190 N UNION ST
Practice Address - Street 2:STE 104
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44304-1369
Practice Address - Country:US
Practice Address - Phone:330-253-9145
Practice Address - Fax:330-253-6222
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN-112443367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH120780OtherKAISER PERMANENTE INDV #
OH7091249Medicaid
OH730594OtherBUCKEYE COMMUNITY HLTH PL
OH100153OtherEMPLOYER KAISER GROUP #
OH2080224OtherEMP UNITED HEALTHCARE GRP
OH000000125767OtherANTHEM BCBS INDV NUMBER
OH0842128Medicaid
OH100153OtherEMPLOYER KAISER GROUP #
OHMI8212461Medicare ID - Type UnspecifiedMEDICARE INDV NUMBER
OH7091249Medicaid