=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992321541
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREINA KATHERINE STEVENSON CRNA, DNAP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2020
-----------------------------------------------------
Last Update Date | 06/19/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 860 OAK PARK BLVD STE 102
-----------------------------------------------------
City | ARROYO GRANDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93420-1800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-476-6383
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1236 GEORGE ST
-----------------------------------------------------
City | SAN LUIS OBISPO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93401-4116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-905-8924
-----------------------------------------------------
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 | 95001348
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------