Healthcare Provider Details

I. General information

NPI: 1124182613
Provider Name (Legal Business Name): KRISTINE NIKOLAI CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 08/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 RIDGE ST
STOUGHTON WI
53589-1864
US

IV. Provider business mailing address

900 RIDGE ST
STOUGHTON WI
53589-1864
US

V. Phone/Fax

Practice location:
  • Phone: 608-873-6611
  • Fax: 608-873-2255
Mailing address:
  • Phone: 608-873-6611
  • Fax: 608-873-2255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4337500
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: