=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477514040
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LORRAINE MARIE HABAN CRNA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2006
-----------------------------------------------------
Last Update Date | 10/04/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 801 S ADAMS ST
-----------------------------------------------------
City | PETERSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23803-5133
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-862-5000
-----------------------------------------------------
Fax | 804-862-5948
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3510 N LOOP 1604 E
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78247-2303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-375-7790
-----------------------------------------------------
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 | 939613
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | 0024165854
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------