MEDICARE: PAMELA CONDLYFFE 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	4704219975	MI

General Provider Information

NPI Number	:	1316930928
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAMELA CONDLYFFE CRNA

Provider Business Mailing Address
First Line	:	255 W MICHIGAN AVE
Second Line	:	P.O. BOX 1123
City	:	JACKSON
State	:	MI
Zip	:	49201-2218
Country	:	US
Telephone Number	:	517-787-6440
Fax Number	:	517-787-4146

Provider Business Practice Location Address
First Line	:	300 NORTH AVE
Second Line	:
City	:	BATTLE CREEK
State	:	MI
Zip	:	49017-3307
Country	:	US
Telephone Number	:	616-966-8000
Fax Number	:

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

Provider Enumeration Date	:	08/30/2005
Last Update Date	:	03/04/2008

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