Healthcare Provider Details

I. General information

NPI: 1083365027
Provider Name (Legal Business Name): LAURA MARIE HERTZEL CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2022
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 E SOUTH TEMPLE
SALT LAKE CITY UT
84102-1507
US

IV. Provider business mailing address

1050 E SOUTH TEMPLE
SALT LAKE CITY UT
84102-1507
US

V. Phone/Fax

Practice location:
  • Phone: 913-707-4773
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number139246
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number16199
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: