Healthcare Provider Details

I. General information

NPI: 1760735054
Provider Name (Legal Business Name): GREGORY LANCE NOEL CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2012
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 GOODMAN ST
CINCINNATI OH
45219-2364
US

IV. Provider business mailing address

PO BOX 636256 CENTRAL CREDENTALING
CINCINNATI OH
45263-6256
US

V. Phone/Fax

Practice location:
  • Phone: 513-558-4194
  • Fax: 513-558-0995
Mailing address:
  • Phone: 513-558-5502
  • Fax: 513-585-5511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1106897
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.364101
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN11011916
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCOA.14120-NA
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: