Healthcare Provider Details

I. General information

NPI: 1669503314
Provider Name (Legal Business Name): LISSA BLAHNIK CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 W ERIE ST UNIT 1303
CHICAGO IL
60610-6456
US

IV. Provider business mailing address

510 W ERIE ST UNIT 1303
CHICAGO IL
60610-6456
US

V. Phone/Fax

Practice location:
  • Phone: 312-440-0553
  • Fax:
Mailing address:
  • Phone: 312-440-0553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209005387
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: