Healthcare Provider Details

I. General information

NPI: 1801105960
Provider Name (Legal Business Name): BETH NICOLE LANGE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2010
Last Update Date: 10/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 JACKSON ST
SAINT PAUL MN
55101-2502
US

IV. Provider business mailing address

689 KINGFISHER LN APT L
WOODBURY MN
55125-1847
US

V. Phone/Fax

Practice location:
  • Phone: 651-254-4784
  • Fax:
Mailing address:
  • Phone: 651-738-9702
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number085074
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: