Healthcare Provider Details

I. General information

NPI: 1922479195
Provider Name (Legal Business Name): ALEXA M HONSTAD CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2015
Last Update Date: 02/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MEMORIAL MEDICAL CENTER, INC 1615 MAPLE LANE
ASHLAND WI
54806
US

IV. Provider business mailing address

1615 MAPLE LANE
ASHLAND WI
54806
US

V. Phone/Fax

Practice location:
  • Phone: 715-685-5500
  • Fax: 715-682-4022
Mailing address:
  • Phone: 715-685-5500
  • Fax: 715-682-4022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number6684-33
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number6684-33
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number167904-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: