Healthcare Provider Details

I. General information

NPI: 1780914465
Provider Name (Legal Business Name): JENNIFER VITALE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2010
Last Update Date: 01/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2540 HANFORD LN
AURORA IL
60502-6969
US

IV. Provider business mailing address

116 PRESIDENTIAL BLVD
OSWEGO IL
60543-9816
US

V. Phone/Fax

Practice location:
  • Phone: 815-748-8993
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209007942
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: