Healthcare Provider Details

I. General information

NPI: 1376840736
Provider Name (Legal Business Name): JESSICA ANN BURTON-VIGIL CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2011
Last Update Date: 10/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2247 CALLE CACIQUE
SANTA FE NM
87505-4944
US

IV. Provider business mailing address

2247 CALLE CACIQUE
SANTA FE NM
87505-4944
US

V. Phone/Fax

Practice location:
  • Phone: 719-351-6025
  • Fax:
Mailing address:
  • Phone: 719-351-6025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPN.0990494-CRNA
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: