Healthcare Provider Details

I. General information

NPI: 1114905122
Provider Name (Legal Business Name): CONSTANCE SUSAN CRISWELL CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CONSTANCE SUSAN DRUMMOND CRNA

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 06/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MADRONE ST
WILLITS CA
95490-4225
US

IV. Provider business mailing address

1 MADRONE ST
WILLITS CA
95490-4225
US

V. Phone/Fax

Practice location:
  • Phone: 707-456-3171
  • Fax:
Mailing address:
  • Phone: 707-456-3171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number3189
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: