=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225105828
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TATJANA WARREN CRNA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2006
-----------------------------------------------------
Last Update Date | 12/16/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30 N 1900 E RM 3C444
-----------------------------------------------------
City | SALT LAKE CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84132-2501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-581-6393
-----------------------------------------------------
Fax | 801-581-4367
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 864 W 100 S
-----------------------------------------------------
City | SALT LAKE CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84104-1107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-405-1003
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | 209.006276 041.35336
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------