Healthcare Provider Details

I. General information

NPI: 1346227576
Provider Name (Legal Business Name): AMY M ICE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 02/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4519 N GARFIELD ST SUITE 15
MIDLAND TX
79705-3415
US

IV. Provider business mailing address

PO BOX 4157
MIDLAND TX
79704-4157
US

V. Phone/Fax

Practice location:
  • Phone: 432-520-0291
  • Fax: 432-520-2723
Mailing address:
  • Phone: 432-520-0291
  • Fax: 432-520-2723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number648252
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: