Healthcare Provider Details

I. General information

NPI: 1790897445
Provider Name (Legal Business Name): DALE HOWARD JOHANSEN CRNA, MSN, ARNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 03/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W HUTCHINGS ST
WINTERSET IA
50273-2109
US

IV. Provider business mailing address

1070 3RD ST
WAUKEE IA
50263-9755
US

V. Phone/Fax

Practice location:
  • Phone: 515-462-5208
  • Fax:
Mailing address:
  • Phone: 515-987-8241
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberD081538
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: