Healthcare Provider Details

I. General information

NPI: 1235677352
Provider Name (Legal Business Name): MOLLY BELVILLE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2017
Last Update Date: 04/07/2020
Certification Date: 04/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E CARPENTER ST
SPRINGFIELD IL
62769-1000
US

IV. Provider business mailing address

800 E CARPENTER ST
SPRINGFIELD IL
62769-1000
US

V. Phone/Fax

Practice location:
  • Phone: 217-544-6464
  • Fax: 217-757-6537
Mailing address:
  • Phone: 217-544-6464
  • Fax: 217-757-6537

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP133195
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209020957
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: