Healthcare Provider Details

I. General information

NPI: 1336673292
Provider Name (Legal Business Name): TAMARA L POULSON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2017
Last Update Date: 02/20/2023
Certification Date: 02/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6644 E BAYWOOD AVE
MESA AZ
85206-1747
US

IV. Provider business mailing address

PO BOX 22487
GREEN BAY WI
54305-2487
US

V. Phone/Fax

Practice location:
  • Phone: 480-321-2000
  • Fax:
Mailing address:
  • Phone: 920-445-7222
  • Fax: 920-445-7289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN160031
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA1475
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: