Healthcare Provider Details

I. General information

NPI: 1063956035
Provider Name (Legal Business Name): KRISTAIN DRU CARROLL CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2016
Last Update Date: 07/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1008 N MAIN ST
SIKESTON MO
63801
US

IV. Provider business mailing address

301 HILLVIEW ST
CAPE GIRARDEAU MO
63703-6329
US

V. Phone/Fax

Practice location:
  • Phone: 573-275-0214
  • Fax:
Mailing address:
  • Phone: 573-275-0214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2011022765
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2017012413
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: