Healthcare Provider Details

I. General information

NPI: 1700837085
Provider Name (Legal Business Name): STEPHANIE DINES CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 S LAKE PARK AVE
HOBART IN
46342-6638
US

IV. Provider business mailing address

1500 S LAKE PARK AVE
HOBART IN
46342-6638
US

V. Phone/Fax

Practice location:
  • Phone: 219-947-6695
  • Fax: 219-947-6092
Mailing address:
  • Phone: 219-947-6695
  • Fax: 219-947-6092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number28109629A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: