Provider Demographics
NPI:1447594858
Name:MERRICK, ADRIENNE L (CRNA)
Entity type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:L
Last Name:MERRICK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:ADRIENNE
Other - Middle Name:L
Other - Last Name:LAFOLLETTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 640446
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45264-0446
Mailing Address - Country:US
Mailing Address - Phone:717-263-5562
Mailing Address - Fax:717-263-1566
Practice Address - Street 1:2222 PHILADELPHIA DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45406-1813
Practice Address - Country:US
Practice Address - Phone:937-734-2612
Practice Address - Fax:937-567-4163
Is Sole Proprietor?:No
Enumeration Date:2012-11-26
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN378232367500000X
INCERT 92108367500000X
IN28174773A163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000001027762OtherANTHEM PROVIDER NUMBER
OH0080856Medicaid
IN201368570Medicaid
OHH186750Medicare PIN
IN815500158Medicare PIN
IN201368570Medicaid