Healthcare Provider Details

I. General information

NPI: 1811259955
Provider Name (Legal Business Name): SUSANNE RENEE OWENS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2012
Last Update Date: 01/03/2024
Certification Date: 01/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 E SIGLER AVE
MEMPHIS MO
63555-1726
US

IV. Provider business mailing address

6000 HOSPITAL DR P O BOX 551
HANNIBAL MO
63401-6887
US

V. Phone/Fax

Practice location:
  • Phone: 660-465-8511
  • Fax:
Mailing address:
  • Phone: 573-248-5115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number146012
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: