Healthcare Provider Details

I. General information

NPI: 1326102096
Provider Name (Legal Business Name): STEPHANIE FLICK CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 07/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 W 9TH ST
JASPER IN
47546-2514
US

IV. Provider business mailing address

2690 S SAINT ANTHONY RD W
HUNTINGBURG IN
47542-9542
US

V. Phone/Fax

Practice location:
  • Phone: 812-482-0643
  • Fax: 812-482-0214
Mailing address:
  • Phone: 812-630-9654
  • Fax: 812-326-9410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number28153536A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: