MEDICARE: DANA LEIGH SIMON 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	163W00000X	Registered Nurse	4704255835	MI
2	367500000X	Certified Registered Nurse Anesthetist	4704255835	MI

General Provider Information

NPI Number	:	1194118273
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANA LEIGH SIMON CRNA

Provider Business Mailing Address
First Line	:	7081 CEDAR RIDGE DR
Second Line	:
City	:	PORTLAND
State	:	MI
Zip	:	48875-8676
Country	:	US
Telephone Number	:	517-526-3319
Fax Number	:

Provider Business Practice Location Address
First Line	:	405 W GREENLAWN AVE STE 106
Second Line	:
City	:	LANSING
State	:	MI
Zip	:	48910-2889
Country	:	US
Telephone Number	:	517-482-6280
Fax Number	:

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

Provider Enumeration Date	:	03/12/2015
Last Update Date	:	06/08/2015

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