Healthcare Provider Details

I. General information

NPI: 1578802427
Provider Name (Legal Business Name): MICHELLE COUNTOURIOTIS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. MICHELLE RIPKA

II. Dates (important events)

Enumeration Date: 02/12/2013
Last Update Date: 02/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2817 REILLY ROAD MCXC-COD CREDENTIALS WOMACK ARMY MEDICAL CENTER
FORT BRAGG NC
28310-7324
US

IV. Provider business mailing address

2817 REILLY ST WOMACK ARMY MEDICAL CENTER
FORT BRAGG NC
28310-7324
US

V. Phone/Fax

Practice location:
  • Phone: 910-907-8922
  • Fax: 910-907-6069
Mailing address:
  • Phone: 910-907-8922
  • Fax: 910-907-6069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN 105999
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: