Healthcare Provider Details

I. General information

NPI: 1639258791
Provider Name (Legal Business Name): SANDRA BONTATIBUS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3535 SOUTHERN BLVD
KETTERING OH
45429-1221
US

IV. Provider business mailing address

4907 SWEETBELL CT
DAYTON OH
45424-4825
US

V. Phone/Fax

Practice location:
  • Phone: 513-839-0903
  • Fax:
Mailing address:
  • Phone: 513-839-0903
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number246893
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: