Healthcare Provider Details

I. General information

NPI: 1154326874
Provider Name (Legal Business Name): BRENDA RAE RUTHERFORD CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BRENDA RAE CRONK CRNA

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 01/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 NW NORTH RIDGE DRIVE, SUITE B ANESTHESIA SERVICES OF BLUE SPRINGS
BLUE SPRINGS MO
64015-6320
US

IV. Provider business mailing address

209 NW NORTH RIDGE DRIVE, SUITE B ANESTHESIA SERVICES OF BLUE SPRINGS
BLUE SPRINGS MO
64015-6320
US

V. Phone/Fax

Practice location:
  • Phone: 816-988-8415
  • Fax: 816-988-8395
Mailing address:
  • Phone: 816-988-8415
  • Fax: 816-988-8395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR0081080
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2002021268
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: