Healthcare Provider Details

I. General information

NPI: 1275800302
Provider Name (Legal Business Name): JONELLE LYNAE VALLIER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2011
Last Update Date: 12/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 RUSH DRIVE
SALIDA CO
81291
US

IV. Provider business mailing address

PO BOX 2626
FORT WORTH TX
76113-2626
US

V. Phone/Fax

Practice location:
  • Phone: 719-290-1367
  • Fax:
Mailing address:
  • Phone: 817-294-7444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number88951
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: