Healthcare Provider Details

I. General information

NPI: 1609877182
Provider Name (Legal Business Name): BETTY A BENDER CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 05/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8990 SPRINGBROOK DR NW SUITE 250
COON RAPIDS MN
55433-5850
US

IV. Provider business mailing address

18150 FOREST RD N
FOREST LAKE MN
55025-8104
US

V. Phone/Fax

Practice location:
  • Phone: 763-398-0099
  • Fax: 763-398-0124
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR0920915
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: