Healthcare Provider Details

I. General information

NPI: 1104861889
Provider Name (Legal Business Name): SUSAN E STEBBINS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 11/29/2023
Certification Date: 11/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

908 ALLEN ST
SPRINGFIELD MA
01118-2533
US

IV. Provider business mailing address

PO BOX 983122
BOSTON MA
02298-3122
US

V. Phone/Fax

Practice location:
  • Phone: 413-796-7494
  • Fax: 413-796-7498
Mailing address:
  • Phone: 413-796-7494
  • Fax: 413-796-7498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number167469
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0024188732
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: