Healthcare Provider Details

I. General information

NPI: 1477620508
Provider Name (Legal Business Name): SINTAHYU MULATA CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 01/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11456 SOUTH BROADWAY
CROWN POINT IN
46307-7106
US

IV. Provider business mailing address

11456 SOUTH BROADWAY
CROWN POINT IN
46307-7106
US

V. Phone/Fax

Practice location:
  • Phone: 219-948-8015
  • Fax: 219-661-1408
Mailing address:
  • Phone: 219-948-8015
  • Fax: 219-661-1408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number28074199A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number430060834
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: