Healthcare Provider Details

I. General information

NPI: 1568666345
Provider Name (Legal Business Name): ROXANE HENKE CRNA, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 03/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240 BURKE RD
MIDDLE RIVER MD
21220-4415
US

IV. Provider business mailing address

1240 BURKE RD
MIDDLE RIVER MD
21220-4415
US

V. Phone/Fax

Practice location:
  • Phone: 410-335-7472
  • Fax: 410-335-7472
Mailing address:
  • Phone: 410-335-7472
  • Fax: 410-335-7472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR069548
License Number StateMD

VIII. Authorized Official

Name: ROXANE LEE HENKE
Title or Position: OWNER
Credential: CRN A
Phone: 410-335-7472