Healthcare Provider Details

I. General information

NPI: 1366770117
Provider Name (Legal Business Name): HEATHER STEPHANIE MCMILLEN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2009
Last Update Date: 02/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

339 CONSORT DR
BALLWIN MO
63011-4439
US

IV. Provider business mailing address

4460 GIBSON AVE
SAINT LOUIS MO
63110-1614
US

V. Phone/Fax

Practice location:
  • Phone: 503-851-7603
  • Fax:
Mailing address:
  • Phone: 503-851-7603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number089666
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: