Healthcare Provider Details

I. General information

NPI: 1942573944
Provider Name (Legal Business Name): STEPHANIE A OSBORNE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANIE A CUPP CRNA

II. Dates (important events)

Enumeration Date: 02/22/2012
Last Update Date: 06/08/2021
Certification Date: 06/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E CARPENTER ST
SPRINGFIELD IL
62769-0002
US

IV. Provider business mailing address

2 GOOD SAMARITAN WAY STE 205
MOUNT VERNON IL
62864-2476
US

V. Phone/Fax

Practice location:
  • Phone: 217-525-5643
  • Fax: 217-544-3311
Mailing address:
  • Phone: 618-889-3869
  • Fax: 618-899-3558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209009395
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: