Healthcare Provider Details

I. General information

NPI: 1487769717
Provider Name (Legal Business Name): SALLY REICHERT CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SALLY REICHERT CRNA

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 02/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 PROSPECT DR
GLENDIVE MT
59330-1943
US

IV. Provider business mailing address

202 PROSPECT DR
GLENDIVE MT
59330-1943
US

V. Phone/Fax

Practice location:
  • Phone: 406-345-3306
  • Fax: 406-345-3358
Mailing address:
  • Phone: 406-345-3306
  • Fax: 406-345-3358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR17896
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number22142
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: