Healthcare Provider Details

I. General information

NPI: 1558786152
Provider Name (Legal Business Name): KRISTA L. MILLER CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/19/2014
Last Update Date: 05/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 W LINCOLN ST STE 101
BELLEVILLE IL
62220-1902
US

IV. Provider business mailing address

311 W LINCOLN ST STE 101
BELLEVILLE IL
62220-1902
US

V. Phone/Fax

Practice location:
  • Phone: 618-222-3200
  • Fax: 618-222-3203
Mailing address:
  • Phone: 182-223-2006
  • Fax: 618-222-3203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209.011240
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: