Healthcare Provider Details

I. General information

NPI: 1114972858
Provider Name (Legal Business Name): CHRISTINE SUE ROTH CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHRISTINE SUE SIMS CRNA

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 MONTGOMERY ST
DECORAH IA
52101-2325
US

IV. Provider business mailing address

901 MONTGOMERY ST
DECORAH IA
52101-2325
US

V. Phone/Fax

Practice location:
  • Phone: 563-382-2911
  • Fax: 563-387-3102
Mailing address:
  • Phone: 563-382-2911
  • Fax: 563-387-3102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberD102488
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: