Healthcare Provider Details

I. General information

NPI: 1649232638
Provider Name (Legal Business Name): STEPHEN M JEWELL CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 01/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 N 4TH ST
CLINTON IA
52732-2940
US

IV. Provider business mailing address

3400 DEXTER CT
DAVENPORT IA
52807-3461
US

V. Phone/Fax

Practice location:
  • Phone: 563-244-5555
  • Fax:
Mailing address:
  • Phone: 563-344-6667
  • Fax: 563-344-6740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberD-108642
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: