MEDICARE: MRS. REBECCA RANGE CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	209-002256	IL
2	367500000X	Certified Registered Nurse Anesthetist	130864	MO
3	367500000X	Certified Registered Nurse Anesthetist	209002256	IL
4	367500000X	Certified Registered Nurse Anesthetist	290671	AZ

General Provider Information

NPI Number	:	1073790747
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. REBECCA RANGE CRNA

Provider Business Mailing Address
First Line	:	13523 BARRETT PARKWAY DRIVE
Second Line	:	SUITE 104
City	:	BALLWIN
State	:	MO
Zip	:	63021-3802
Country	:	US
Telephone Number	:	636-938-6868
Fax Number	:	636-938-1486

Provider Business Practice Location Address
First Line	:	6501 N 19TH AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85015-1646
Country	:	US
Telephone Number	:	602-795-6020
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/24/2008
Last Update Date	:	02/29/2024

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