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General NPI Number Information
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NPI Number | 1134434962
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Entity Type | Individual
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Provider Name | JENELLE LYNN FYE CRNA
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Gender | Female
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Dates
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Enumeration Date | 08/17/2010
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Last Update Date | 06/29/2011
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Provider Practice Location Address
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Address Line | 1221 PINE GROVE AVE
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City | PORT HURON
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State | MI
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Zip | 48060-3511
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Country | US
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Telephone | 810-987-5000
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Fax |
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Provider Business Mailing Address
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Address Line | 3204 STRAWBERRY LN
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City | PORT HURON
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State | MI
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Zip | 48060-2306
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Country | US
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Telephone | 810-334-9006
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 4704243706
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | 4704243706
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License Number State | MI
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