Healthcare Provider Details

I. General information

NPI: 1033101894
Provider Name (Legal Business Name): ANDREA J ANDERSON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANDREA J KVAMME CRNA

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 11/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 WHIPPLE ST
EAU CLAIRE WI
54703-5270
US

IV. Provider business mailing address

2107 HEIGHTS DR
EAU CLAIRE WI
54701-6130
US

V. Phone/Fax

Practice location:
  • Phone: 715-838-3311
  • Fax:
Mailing address:
  • Phone: 715-834-8721
  • Fax: 715-834-3087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number148588
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: