Healthcare Provider Details

I. General information

NPI: 1548366412
Provider Name (Legal Business Name): BRENDA J PAYNE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7330 STATE HIGHWAY 7
EXCELSIOR MN
55331
US

IV. Provider business mailing address

4137 PARK AVE
MINNEAPOLIS MN
55407-3128
US

V. Phone/Fax

Practice location:
  • Phone: 651-257-2251
  • Fax: 651-257-2261
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR0800747
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: