Healthcare Provider Details

I. General information

NPI: 1043442981
Provider Name (Legal Business Name): TINA MCCLAIN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2009
Last Update Date: 08/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 W NORFOLK AVE
NORFOLK NE
68701-4438
US

IV. Provider business mailing address

110 N 29TH ST SUITE 201
NORFOLK NE
68701-4424
US

V. Phone/Fax

Practice location:
  • Phone: 402-644-7556
  • Fax: 402-644-7647
Mailing address:
  • Phone: 402-844-8121
  • Fax: 402-844-8122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number69406
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number101103
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: