Healthcare Provider Details

I. General information

NPI: 1568069474
Provider Name (Legal Business Name): EMMA MARIE LEE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: EMMA MARIE BRANDENBURG

II. Dates (important events)

Enumeration Date: 10/04/2020
Last Update Date: 12/27/2023
Certification Date: 12/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1575 BEAM AVE
SAINT PAUL MN
55109-1126
US

IV. Provider business mailing address

14700 28TH AVE N STE 20
PLYMOUTH MN
55447-4876
US

V. Phone/Fax

Practice location:
  • Phone: 651-232-7000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number133882
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: