Healthcare Provider Details

I. General information

NPI: 1457418071
Provider Name (Legal Business Name): SUSAN ANNICELLI CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USA MEDDAC, RWBAHC 2240E. WINROW AVE
FORT HUACHUCA AZ
85613-7079
US

IV. Provider business mailing address

1518 GRIERSON AVE
FORT HUACHUCA AZ
85613
US

V. Phone/Fax

Practice location:
  • Phone: 520-533-9026
  • Fax:
Mailing address:
  • Phone: 520-533-9026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number108867
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: