Healthcare Provider Details

I. General information

NPI: 1386008035
Provider Name (Legal Business Name): GINA NEWBERRY CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GINA BUTLER CRNA

II. Dates (important events)

Enumeration Date: 04/08/2016
Last Update Date: 01/08/2020
Certification Date: 01/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12303 DE PAUL DR
BRIDGETON MO
63044-2512
US

IV. Provider business mailing address

13515 BARRETT PARKWAY DR SUITE 170
BALLWIN MO
63021-5870
US

V. Phone/Fax

Practice location:
  • Phone: 469-757-1042
  • Fax: 855-917-2066
Mailing address:
  • Phone: 469-757-1042
  • Fax: 855-917-2066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2009030293
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: