Healthcare Provider Details

I. General information

NPI: 1134682495
Provider Name (Legal Business Name): JOANNA M MINETTI CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2019
Last Update Date: 07/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 W IRONWOOD DR STE 250
COEUR D ALENE ID
83814-1415
US

IV. Provider business mailing address

PO BOX 35145 #40023
SEATTLE WA
98124-5145
US

V. Phone/Fax

Practice location:
  • Phone: 208-765-8585
  • Fax:
Mailing address:
  • Phone: 425-407-1000
  • Fax: 425-407-1112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP60975346
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number58330
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: