Healthcare Provider Details

I. General information

NPI: 1740250059
Provider Name (Legal Business Name): KOKO CAMITA CANTRELL CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USA MEDDAC. EVANS ARMY COMMUNITY HOSPITAL ANESTHESIA DEPT
FORT CARSON CO
80913-4604
US

IV. Provider business mailing address

250 THAMES DR
COLORADO SPRINGS CO
80906-5951
US

V. Phone/Fax

Practice location:
  • Phone: 719-526-7944
  • Fax:
Mailing address:
  • Phone: 719-520-0874
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number125811
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: