Healthcare Provider Details

I. General information

NPI: 1104177724
Provider Name (Legal Business Name): JENNIFER L CRIPPS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2012
Last Update Date: 10/28/2022
Certification Date: 10/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SAINT ELIZABETH BLVD
O FALLON IL
62269-1099
US

IV. Provider business mailing address

1 SAINT ELIZABETH BLVD
O FALLON IL
62269-1099
US

V. Phone/Fax

Practice location:
  • Phone: 618-234-2120
  • Fax:
Mailing address:
  • Phone: 618-234-2120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number75285
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209021202
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: