Healthcare Provider Details

I. General information

NPI: 1609184043
Provider Name (Legal Business Name): AMANDA JEAN GROSS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA JEAN HORNUNG CRNA

II. Dates (important events)

Enumeration Date: 09/20/2010
Last Update Date: 04/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 32ND AVE S
FARGO ND
58103-6132
US

IV. Provider business mailing address

PO BOX 6001
FARGO ND
58108-6001
US

V. Phone/Fax

Practice location:
  • Phone: 701-364-8000
  • Fax:
Mailing address:
  • Phone: 701-364-8000
  • Fax: 701-364-8078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR30715
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR176928-5
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: