Healthcare Provider Details

I. General information

NPI: 1912107780
Provider Name (Legal Business Name): DIANE E THOMAS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DIANE E GRINDSTAFF

II. Dates (important events)

Enumeration Date: 07/20/2007
Last Update Date: 07/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3045 S NATIONAL AVE SUITE 101
SPRINGFIELD MO
65804-4268
US

IV. Provider business mailing address

3045 S NATIONAL AVE SUITE 100
SPRINGFIELD MO
65804-4268
US

V. Phone/Fax

Practice location:
  • Phone: 417-882-1900
  • Fax: 417-882-1966
Mailing address:
  • Phone: 417-882-1900
  • Fax: 417-882-1966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number130338
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number130338
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: