Healthcare Provider Details

I. General information

NPI: 1851605653
Provider Name (Legal Business Name): JENNIFER LYNN DELARUELLE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER LYNN SANDS

II. Dates (important events)

Enumeration Date: 08/04/2010
Last Update Date: 12/07/2021
Certification Date: 12/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1032 E SUMNER ST
HARTFORD WI
53027-1608
US

IV. Provider business mailing address

W351N5434 LAKE DR
OCONOMOWOC WI
53066-2516
US

V. Phone/Fax

Practice location:
  • Phone: 262-670-7260
  • Fax:
Mailing address:
  • Phone: 920-309-0086
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number131677-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: