Healthcare Provider Details

I. General information

NPI: 1750912515
Provider Name (Legal Business Name): ALICIA BOENISH CRNA, DNAP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2020
Last Update Date: 01/30/2020
Certification Date: 01/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 BROADWAY
SEATTLE WA
98122-4379
US

IV. Provider business mailing address

1220 CENTER ST W
ROCHESTER MN
55902-0306
US

V. Phone/Fax

Practice location:
  • Phone: 206-386-6000
  • Fax:
Mailing address:
  • Phone: 507-269-0137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number124036
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: