Healthcare Provider Details

I. General information

NPI: 1205984366
Provider Name (Legal Business Name): STANLEY ANSEL KRISTIANSEN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: STANLEY ANSEL KRISTIANSEN CRNA

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 05/10/2023
Certification Date: 05/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3249 OAK PARK AVE
BERWYN IL
60402-3429
US

IV. Provider business mailing address

PO BOX 38
CORYDON IN
47112-0038
US

V. Phone/Fax

Practice location:
  • Phone: 708-783-3013
  • Fax:
Mailing address:
  • Phone: 812-738-4251
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number3006664
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209027161
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: