Healthcare Provider Details

I. General information

NPI: 1841502549
Provider Name (Legal Business Name): AIMEE SHANE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2010
Last Update Date: 02/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1051 W SOUTH ST
KEWANEE IL
61443-8354
US

IV. Provider business mailing address

278 PIN OAK CT
DAHINDA IL
61428-9769
US

V. Phone/Fax

Practice location:
  • Phone: 309-852-7500
  • Fax:
Mailing address:
  • Phone: 309-339-1259
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209.008194
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: