Healthcare Provider Details

I. General information

NPI: 1023101383
Provider Name (Legal Business Name): AUBREY FOLSOM MONCRIEF CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2006
Last Update Date: 10/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5470 STONE LEDGE CIR
OSAGE BEACH MO
65065-2554
US

IV. Provider business mailing address

PO BOX 264
OSAGE BEACH MO
65065-0264
US

V. Phone/Fax

Practice location:
  • Phone: 573-302-0836
  • Fax: 573-302-0863
Mailing address:
  • Phone: 573-302-0836
  • Fax: 573-302-0863

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number084548
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209-001689
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704131876
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: