Healthcare Provider Details

I. General information

NPI: 1881671550
Provider Name (Legal Business Name): KATHLEEN MARIE EWERS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2005
Last Update Date: 08/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CMR 442 BOX678
APO AE
09042
DE

IV. Provider business mailing address

3003 CARLISLE CT
SUFFOLK VA
23435-2560
US

V. Phone/Fax

Practice location:
  • Phone: 720-240-9851
  • Fax:
Mailing address:
  • Phone: 720-240-9851
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number676080
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: