Healthcare Provider Details

I. General information

NPI: 1215569652
Provider Name (Legal Business Name): CASEY LAINE PESCH CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/04/2020
Last Update Date: 02/04/2020
Certification Date: 02/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 S COLUMBIA RD
GRAND FORKS ND
58201-4044
US

IV. Provider business mailing address

1200 S COLUMBIA RD
GRAND FORKS ND
58201-4044
US

V. Phone/Fax

Practice location:
  • Phone: 701-740-7283
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR35941
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: