Healthcare Provider Details

I. General information

NPI: 1891148094
Provider Name (Legal Business Name): STEFANY MCMULLEN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2016
Last Update Date: 11/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5230 EOLA DR NW
SALEM OR
97304-3355
US

IV. Provider business mailing address

5230 EOLA DR NW
SALEM OR
97304-3355
US

V. Phone/Fax

Practice location:
  • Phone: 661-699-4532
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number201608320CRNA-PP
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number200843420RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: