Healthcare Provider Details

I. General information

NPI: 1093033474
Provider Name (Legal Business Name): AMANDA AHRENS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2010
Last Update Date: 03/29/2021
Certification Date: 03/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 N EAST AVE
JACKSON MI
49201
US

IV. Provider business mailing address

PO BOX 64000 DRAWER 541535
DETROIT MI
48264-0001
US

V. Phone/Fax

Practice location:
  • Phone: 517-788-4800
  • Fax:
Mailing address:
  • Phone: 734-786-8052
  • Fax: 734-786-4932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704237420
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704237420
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: