Healthcare Provider Details

I. General information

NPI: 1659458933
Provider Name (Legal Business Name): SANDRA K RICHARD CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SANDRA K NORRIS CRNA

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 08/25/2020
Certification Date: 08/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

93 CAMPUS AVE
LEWISTON ME
04240-6030
US

IV. Provider business mailing address

C/O ST MARYS HEALTH SYSTEM - PROVIDER ENROLLMENT PO BOX 7291
LEWISTON ME
04243-7291
US

V. Phone/Fax

Practice location:
  • Phone: 207-777-8442
  • Fax: 207-777-8425
Mailing address:
  • Phone: 207-777-8950
  • Fax: 207-777-8800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRNA83198
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: