Healthcare Provider Details

I. General information

NPI: 1073041794
Provider Name (Legal Business Name): LAURA WHALEN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2017
Last Update Date: 05/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST
BOSTON MA
02114-2621
US

IV. Provider business mailing address

12 MITCHELL ST APT 3
SOUTH BOSTON MA
02127-2819
US

V. Phone/Fax

Practice location:
  • Phone: 617-726-2000
  • Fax:
Mailing address:
  • Phone: 774-286-9381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number115241
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: