Healthcare Provider Details

I. General information

NPI: 1073790747
Provider Name (Legal Business Name): REBECCA RANGE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2008
Last Update Date: 02/29/2024
Certification Date: 02/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6501 N 19TH AVE
PHOENIX AZ
85015-1646
US

IV. Provider business mailing address

13523 BARRETT PARKWAY DRIVE SUITE 104
BALLWIN MO
63021-3802
US

V. Phone/Fax

Practice location:
  • Phone: 602-795-6020
  • Fax:
Mailing address:
  • Phone: 636-938-6868
  • Fax: 636-938-1486

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209-002256
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number130864
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209002256
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number290671
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: