Healthcare Provider Details

I. General information

NPI: 1184725723
Provider Name (Legal Business Name): CONNIE J BOLIN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 04/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E 28TH ST
MINNEAPOLIS MN
55407-3723
US

IV. Provider business mailing address

10310 STATE LINE RD SUITE A
LEAWOOD KS
66206-2658
US

V. Phone/Fax

Practice location:
  • Phone: 865-342-8900
  • Fax:
Mailing address:
  • Phone: 913-647-4101
  • Fax: 913-647-4121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number096957
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA 1929
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: