Healthcare Provider Details

I. General information

NPI: 1396162947
Provider Name (Legal Business Name): KAREN ROOF CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2014
Last Update Date: 08/25/2020
Certification Date: 08/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E CARPENTER ST
SPRINGFIELD IL
62769-2329
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 TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209021852
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: