Healthcare Provider Details

I. General information

NPI: 1033241153
Provider Name (Legal Business Name): DUSTIN DAIGLE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 11/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 MCMILLAN RD
WEST MONROE LA
71291-5327
US

IV. Provider business mailing address

925 SHERWOOD DR
LAKE BLUFF IL
60044-2203
US

V. Phone/Fax

Practice location:
  • Phone: 318-329-4200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN107291
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: