Healthcare Provider Details

I. General information

NPI: 1689667396
Provider Name (Legal Business Name): LOUANN SITES CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 HOPE DR
MOUNTAIN HOME A F B ID
83648-1057
US

IV. Provider business mailing address

1530 PEREGRINE DR
MOUNTAIN HOME ID
83647-4434
US

V. Phone/Fax

Practice location:
  • Phone: 208-828-7370
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN039094
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: