Healthcare Provider Details

I. General information

NPI: 1053632687
Provider Name (Legal Business Name): KRYSTLE MARIE DOROBEK CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRYSTLE MARIE HITESHEW CRNA

II. Dates (important events)

Enumeration Date: 06/17/2010
Last Update Date: 04/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5450 FORT STREET ANESTHESIA DEPARTMENT
TRENTON MI
48183
US

IV. Provider business mailing address

PO BOX 67000 DEPT 212501
DETROIT MI
48267-0001
US

V. Phone/Fax

Practice location:
  • Phone: 734-671-6800
  • Fax:
Mailing address:
  • Phone: 734-671-6800
  • Fax: 734-671-3891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704253093
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: