Healthcare Provider Details

I. General information

NPI: 1336193622
Provider Name (Legal Business Name): CAROLYN ELMBORG CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 04/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5752 RIDGE TRL
JOPLIN MO
64804-9506
US

IV. Provider business mailing address

5752 RIDGE TRL
JOPLIN MO
64804-9506
US

V. Phone/Fax

Practice location:
  • Phone: 417-437-0357
  • Fax: 417-624-5741
Mailing address:
  • Phone: 417-437-0357
  • Fax: 417-624-5741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number056659
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: