Healthcare Provider Details

I. General information

NPI: 1396011847
Provider Name (Legal Business Name): JAYME S VIVIAN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2012
Last Update Date: 10/10/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E CHERRY ST
TROY MO
63379-1513
US

IV. Provider business mailing address

1000 E CHERRY ST
TROY MO
63379-1513
US

V. Phone/Fax

Practice location:
  • Phone: 636-528-3265
  • Fax:
Mailing address:
  • Phone: 636-528-3265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2006021763
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: