Healthcare Provider Details

I. General information

NPI: 1669805313
Provider Name (Legal Business Name): EMILY A WARNER CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: EMILY A HEREDIA CRNA

II. Dates (important events)

Enumeration Date: 08/16/2013
Last Update Date: 12/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 EASTLAND DR SUITE LL1000
BLOOMINGTON IL
61701-3534
US

IV. Provider business mailing address

1505 EASTLAND DR SUITE LL1000
BLOOMINGTON IL
61701-3534
US

V. Phone/Fax

Practice location:
  • Phone: 309-663-4700
  • Fax: 309-665-0575
Mailing address:
  • Phone: 309-663-4700
  • Fax: 309-665-0575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209010546
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: