Healthcare Provider Details

I. General information

NPI: 1760131742
Provider Name (Legal Business Name): STANI KURIAKOSE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2022
Last Update Date: 10/01/2024
Certification Date: 10/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 RIDGE AVE
EVANSTON IL
60201-1700
US

IV. Provider business mailing address

998 CHURCH ST UNIT 429
GLENVIEW IL
60025-3093
US

V. Phone/Fax

Practice location:
  • Phone: 847-570-2000
  • Fax:
Mailing address:
  • Phone: 469-855-4543
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209024923
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.519832
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number209.024923
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: