Healthcare Provider Details

I. General information

NPI: 1851801203
Provider Name (Legal Business Name): AMY BETH TEVIS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMY BETH JOHNSON CRNA

II. Dates (important events)

Enumeration Date: 10/11/2017
Last Update Date: 10/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 MANKATO AVE
WINONA MN
55987-4868
US

IV. Provider business mailing address

525 21ST AVE S
ONALASKA WI
54650-8751
US

V. Phone/Fax

Practice location:
  • Phone: 800-944-3960
  • Fax:
Mailing address:
  • Phone: 608-385-4192
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number118457
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: