Healthcare Provider Details

I. General information

NPI: 1861965212
Provider Name (Legal Business Name): KRISTENA JORDAN SCOTT CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2019
Last Update Date: 01/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 BURKARTH RD
WARRENSBURG MO
64093-3101
US

IV. Provider business mailing address

127 N WINNEBAGO DR
LAKE WINNEBAGO MO
64034-9318
US

V. Phone/Fax

Practice location:
  • Phone: 660-747-2500
  • Fax:
Mailing address:
  • Phone: 615-364-1473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2018043918
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: