Healthcare Provider Details

I. General information

NPI: 1114358520
Provider Name (Legal Business Name): WINIFRED SIDIBE APRN, CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2013
Last Update Date: 05/06/2024
Certification Date: 05/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6401 FRANCE AVE S
EDINA MN
55435-2104
US

IV. Provider business mailing address

11781 LEE JACKSON MEMORIAL HWY STE 550
FAIRFAX VA
22033-3309
US

V. Phone/Fax

Practice location:
  • Phone: 952-924-5000
  • Fax:
Mailing address:
  • Phone: 571-777-5164
  • Fax: 703-890-2650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number679665
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: