Healthcare Provider Details

I. General information

NPI: 1477935112
Provider Name (Legal Business Name): ANNMARIE BACH CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2015
Last Update Date: 08/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19627 S LA GRANGE RD
MOKENA IL
60448-9360
US

IV. Provider business mailing address

2831 RYAN DR
NEW LENOX IL
60451-2633
US

V. Phone/Fax

Practice location:
  • Phone: 708-326-1671
  • Fax:
Mailing address:
  • Phone: 815-717-6621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28211331A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041310711
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209013115
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: