Healthcare Provider Details

I. General information

NPI: 1457345035
Provider Name (Legal Business Name): JOAN ELYSE BACKENSTOE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 04/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3147 COLLEGE HEIGHTS BLVD
ALLENTOWN PA
18104-4813
US

IV. Provider business mailing address

4653 STEVEN LN
WALNUTPORT PA
18088-9619
US

V. Phone/Fax

Practice location:
  • Phone: 610-841-2432
  • Fax: 610-841-4433
Mailing address:
  • Phone: 610-767-3476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN184932L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: