Healthcare Provider Details

I. General information

NPI: 1902425358
Provider Name (Legal Business Name): STACY XAVIER CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2020
Last Update Date: 08/08/2026
Certification Date: 08/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 MACARTHUR BLVD ANESTHESIA DEPARTMENT
MUNSTER IN
46321-2901
US

IV. Provider business mailing address

901 MACARTHUR BLVD ANESTHESIA DEPARTMENT
MUNSTER IN
46321
US

V. Phone/Fax

Practice location:
  • Phone: 219-703-1443
  • Fax: 219-513-1127
Mailing address:
  • Phone: 219-703-1443
  • Fax: 219-513-1127

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9488261
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number28304737A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: