Healthcare Provider Details

I. General information

NPI: 1396237608
Provider Name (Legal Business Name): LIBERTY HANISCH CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2018
Last Update Date: 10/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 W 5TH AVE
SPOKANE WA
99204-2803
US

IV. Provider business mailing address

4223 S MADELIA ST
SPOKANE WA
99203-4322
US

V. Phone/Fax

Practice location:
  • Phone: 910-689-5950
  • Fax:
Mailing address:
  • Phone: 910-589-5950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number243392
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number60894969
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: