Healthcare Provider Details

I. General information

NPI: 1063653103
Provider Name (Legal Business Name): ANGELA D LIDDELL CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANGELA D GULBRANSON

II. Dates (important events)

Enumeration Date: 03/19/2009
Last Update Date: 09/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 E 26TH ST
SIOUX FALLS SD
57105-4046
US

IV. Provider business mailing address

1005 W GOLDEN EAGLE ST
SIOUX FALLS SD
57108-4839
US

V. Phone/Fax

Practice location:
  • Phone: 605-338-7098
  • Fax: 605-335-3505
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN-1171
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: