Healthcare Provider Details

I. General information

NPI: 1104603695
Provider Name (Legal Business Name): SAMANTHA MAE AUFDERHAAR DNP, CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2023
Last Update Date: 09/11/2023
Certification Date: 09/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 NE GLEN OAK AVE
PEORIA IL
61637-0001
US

IV. Provider business mailing address

901 WOODLAND KNOLLS RD
GERMANTOWN HILLS IL
61548-9432
US

V. Phone/Fax

Practice location:
  • Phone: 309-655-2000
  • Fax:
Mailing address:
  • Phone: 608-886-8719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number145026
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: