Healthcare Provider Details

I. General information

NPI: 1770308660
Provider Name (Legal Business Name): SOPHIA MARIE BOTTEMA CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SOPHIE GUYETTE

II. Dates (important events)

Enumeration Date: 11/18/2024
Last Update Date: 04/18/2025
Certification Date: 04/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 W FOUNTAIN ST
ALBERT LEA MN
56007-2406
US

IV. Provider business mailing address

PO BOX 860912
MINNEAPOLIS MN
55486-0912
US

V. Phone/Fax

Practice location:
  • Phone: 507-373-2384
  • Fax:
Mailing address:
  • Phone: 507-284-2511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number3135
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: