Healthcare Provider Details

I. General information

NPI: 1194765909
Provider Name (Legal Business Name): RITA A PRATER CROUCH CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 E LAKE SHORE DR
DECATUR IL
62521-3810
US

IV. Provider business mailing address

820 W PERSHING RD
DECATUR IL
62526-1538
US

V. Phone/Fax

Practice location:
  • Phone: 217-464-2966
  • Fax:
Mailing address:
  • Phone: 217-875-5057
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: