Healthcare Provider Details

I. General information

NPI: 1003223314
Provider Name (Legal Business Name): JENNA SULLIVAN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2014
Last Update Date: 10/20/2022
Certification Date: 10/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7500 MERCY ROAD
OMAHA NE
68124-2319
US

IV. Provider business mailing address

7500 MERCY ROAD
OMAHA NE
68124-2319
US

V. Phone/Fax

Practice location:
  • Phone: 402-398-6060
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number68437
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberD137536
License Number StateIA
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number101259
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: