Healthcare Provider Details

I. General information

NPI: 1922257211
Provider Name (Legal Business Name): JERRY LEE STUFFLE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2008
Last Update Date: 09/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8673 CALHOUN PL
CROWN POINT IN
46307-7713
US

IV. Provider business mailing address

8673 CALHOUN PL
CROWN POINT IN
46307-7713
US

V. Phone/Fax

Practice location:
  • Phone: 219-365-7954
  • Fax:
Mailing address:
  • Phone: 219-365-7954
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number28121816A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number041.313724
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: