Healthcare Provider Details

I. General information

NPI: 1023434396
Provider Name (Legal Business Name): STEPHANIE RUIZ-GONZALEZ CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2014
Last Update Date: 03/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 SOUTH ST
SOUTHBRIDGE MA
01550-4051
US

IV. Provider business mailing address

100 SOUTH ST
SOUTHBRIDGE MA
01550-4051
US

V. Phone/Fax

Practice location:
  • Phone: 508-909-7799
  • Fax:
Mailing address:
  • Phone: 508-909-7799
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN2291156
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: