=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457345035
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOAN ELYSE BACKENSTOE CRNA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2005
-----------------------------------------------------
Last Update Date | 04/11/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3147 COLLEGE HEIGHTS BLVD
-----------------------------------------------------
City | ALLENTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18104-4813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-841-2432
-----------------------------------------------------
Fax | 610-841-4433
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4653 STEVEN LN
-----------------------------------------------------
City | WALNUTPORT
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18088-9619
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-767-3476
-----------------------------------------------------
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 | RN184932L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------