MEDICARE: ADRIENNE CLARK STOVALL C.R.N.A.

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	163WC0200X	Critical Care Medicine Registered Nurse	632098	TX
2	367500000X	Certified Registered Nurse Anesthetist	079563	TX

General Provider Information

NPI Number	:	1831201094
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ADRIENNE CLARK STOVALL C.R.N.A.

Provider Business Mailing Address
First Line	:	601 ELM HILL BLVD
Second Line	:
City	:	BURLESON
State	:	TX
Zip	:	76028-7670
Country	:	US
Telephone Number	:	817-691-2109
Fax Number	:

Provider Business Practice Location Address
First Line	:	2000 E LAMAR BLVD
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76006-7346
Country	:	US
Telephone Number	:	817-861-3994
Fax Number	:

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

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	01/24/2014

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