Healthcare Provider Details

I. General information

NPI: 1588294656
Provider Name (Legal Business Name): JESSICA MILLER CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2020
Last Update Date: 01/17/2020
Certification Date: 01/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 S CEDAR CREST BLVD
ALLENTOWN PA
18103-6202
US

IV. Provider business mailing address

5265 ROCKROSE LN BLDG K34
ALLENTOWN PA
18104-8269
US

V. Phone/Fax

Practice location:
  • Phone: 610-402-8000
  • Fax:
Mailing address:
  • Phone: 917-536-5307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number128454
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: