Healthcare Provider Details

I. General information

NPI: 1528052503
Provider Name (Legal Business Name): LAURIE JEAN MCMULLAN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 CAPEHART RD SGOSA
OFFUTT A F B NE
68113-1043
US

IV. Provider business mailing address

2907 SCHUEMANN DR
BELLEVUE NE
68123-1998
US

V. Phone/Fax

Practice location:
  • Phone: 402-294-2135
  • Fax: 402-294-2816
Mailing address:
  • Phone: 402-884-6476
  • Fax: 402-294-2816

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number100909
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: