Healthcare Provider Details

I. General information

NPI: 1629275532
Provider Name (Legal Business Name): STEPHANIE ANNE ANDERSON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 02/25/2020
Certification Date: 02/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 W TOWNLINE ST
CRESTON IA
50801-1054
US

IV. Provider business mailing address

1700 W TOWNLINE ST
CRESTON IA
50801-1054
US

V. Phone/Fax

Practice location:
  • Phone: 641-782-7091
  • Fax: 641-782-3830
Mailing address:
  • Phone: 641-782-7091
  • Fax: 641-782-3830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberD-108292
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: