Healthcare Provider Details

I. General information

NPI: 1215993985
Provider Name (Legal Business Name): AMY D KOSANKE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMY D FLEETWOOD CRNA

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 01/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 THE CITY DR S
ORANGE CA
92868-3201
US

IV. Provider business mailing address

101 THE CITY DR S
ORANGE CA
92868-3201
US

V. Phone/Fax

Practice location:
  • Phone: 714-456-5261
  • Fax:
Mailing address:
  • Phone: 714-456-5261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN138246
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: