Healthcare Provider Details

I. General information

NPI: 1629088174
Provider Name (Legal Business Name): SANDRA L HAYDEN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SANDRA L HAYDEN CRNA

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 02/10/2023
Certification Date: 02/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 MEMORIAL DR
BELLEVILLE IL
62226
US

IV. Provider business mailing address

PO BOX 66971-CC
ST LOUIS MO
63166
US

V. Phone/Fax

Practice location:
  • Phone: 618-257-5162
  • Fax:
Mailing address:
  • Phone: 866-633-0610
  • Fax: 314-548-4747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209006080
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: