Healthcare Provider Details

I. General information

NPI: 1336647569
Provider Name (Legal Business Name): AMANDA RAE DIETZ CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA RAE CRALLEY

II. Dates (important events)

Enumeration Date: 01/23/2018
Last Update Date: 01/09/2025
Certification Date: 01/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 1ST ST SW
ROCHESTER MN
55905-0002
US

IV. Provider business mailing address

200 1ST ST SW
ROCHESTER MN
55905-0002
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN9350211
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2776
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: