Healthcare Provider Details

I. General information

NPI: 1972934180
Provider Name (Legal Business Name): TANYA FLORENCE WATERBURY CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TANYA FLORENCE KELLOGG CRNA

II. Dates (important events)

Enumeration Date: 12/13/2013
Last Update Date: 04/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1836 SOUTH AVE
LA CROSSE WI
54601-5429
US

IV. Provider business mailing address

1836 SOUTH AVE
LA CROSSE WI
54601-5429
US

V. Phone/Fax

Practice location:
  • Phone: 608-782-7300
  • Fax:
Mailing address:
  • Phone: 608-782-7300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR 185512-8
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number221949
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: