MEDICARE: THERESA MARIE DUFFY 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	R142887-2	MN

General Provider Information

NPI Number	:	1316949050
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESA MARIE DUFFY CRNA

Provider Business Mailing Address
First Line	:	5385 WAHLSTEN RD
Second Line	:
City	:	EMBARRASS
State	:	MN
Zip	:	55732-8613
Country	:	US
Telephone Number	:	218-984-2230
Fax Number	:

Provider Business Practice Location Address
First Line	:	901 9TH ST N
Second Line	:
City	:	VIRGINIA
State	:	MN
Zip	:	55792-2348
Country	:	US
Telephone Number	:	218-749-9457
Fax Number	:

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

Provider Enumeration Date	:	08/12/2005
Last Update Date	:	07/11/2007

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