Healthcare Provider Details

I. General information

NPI: 1861718165
Provider Name (Legal Business Name): JANNA SUE FORD CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2010
Last Update Date: 04/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1304 MILLBAY CT
SAINT LOUIS MO
63129-3171
US

IV. Provider business mailing address

1304 MILLBAY CT
SAINT LOUIS MO
63129-3171
US

V. Phone/Fax

Practice location:
  • Phone: 314-200-8180
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number138425
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: