Healthcare Provider Details

I. General information

NPI: 1548779234
Provider Name (Legal Business Name): STRAVENS OMWENGA CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2017
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 W JACKSON ST
CARBONDALE IL
62901-1462
US

IV. Provider business mailing address

3909 RUTHRIDGE DR
PLANO TX
75074-7785
US

V. Phone/Fax

Practice location:
  • Phone: 618-549-0721
  • Fax:
Mailing address:
  • Phone: 469-733-2200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number112301
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209032524
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: