Healthcare Provider Details

I. General information

NPI: 1922065549
Provider Name (Legal Business Name): CARRIE L SMITH CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CARRIE L VANISACKER CRNA

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 N MACOMB ST
MONROE MI
48162-7813
US

IV. Provider business mailing address

740 N MACOMB ST
MONROE MI
48162-7813
US

V. Phone/Fax

Practice location:
  • Phone: 734-240-5238
  • Fax:
Mailing address:
  • Phone: 734-240-5238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704207344
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: