Healthcare Provider Details

I. General information

NPI: 1710465141
Provider Name (Legal Business Name): JENNIFER LYNN THOMAS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2018
Last Update Date: 09/12/2022
Certification Date: 09/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 E MICHIGAN AVE
GRAYLING MI
49738-1312
US

IV. Provider business mailing address

412 N SPRUCE ST
TRAVERSE CITY MI
49684-2155
US

V. Phone/Fax

Practice location:
  • Phone: 989-348-5461
  • Fax:
Mailing address:
  • Phone: 231-499-1773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704304278
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: