Healthcare Provider Details

I. General information

NPI: 1710763313
Provider Name (Legal Business Name): STEPHANIE NICOLE RODRIQUEZ CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2023
Last Update Date: 08/22/2024
Certification Date: 08/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ONE HOSPITAL DR
COLUMBIA MO
65212-0001
US

IV. Provider business mailing address

1471 N STRATFORD LN
WICHITA KS
67206-1164
US

V. Phone/Fax

Practice location:
  • Phone: 573-882-2568
  • Fax: 855-903-0985
Mailing address:
  • Phone: 831-402-3770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number151169
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2024033973
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: