MEDICARE: ELLEN LOUISE BOYER 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	RN105314	AZ

General Provider Information

NPI Number	:	1174529077
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELLEN LOUISE BOYER CRNA

Provider Business Mailing Address
First Line	:	PO BOX 29211
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85038-9211
Country	:	US
Telephone Number	:	602-273-6770
Fax Number	:	602-889-0489

Provider Business Practice Location Address
First Line	:	1740 SYCAMORE AVE
Second Line	:
City	:	KINGMAN
State	:	AZ
Zip	:	86401-0927
Country	:	US
Telephone Number	:	602-273-6770
Fax Number	:	602-889-0489

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

Provider Enumeration Date	:	06/24/2005
Last Update Date	:	02/21/2008

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