Healthcare Provider Details

I. General information

NPI: 1669719175
Provider Name (Legal Business Name): RACHEL RENEE WALLACE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2013
Last Update Date: 08/08/2022
Certification Date: 07/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1311 N MILDRED RD
CORTEZ CO
81321
US

IV. Provider business mailing address

35505 ROAD K.1
MANCOS CO
81328-8978
US

V. Phone/Fax

Practice location:
  • Phone: 970-555-6666
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR0088890
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberC-APN.0001428-C-CRNA
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: