MEDICARE: MRS. AMY M ICE 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	648252	TX

General Provider Information

NPI Number	:	1346227576
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. AMY M ICE CRNA

Provider Business Mailing Address
First Line	:	PO BOX 4157
Second Line	:
City	:	MIDLAND
State	:	TX
Zip	:	79704-4157
Country	:	US
Telephone Number	:	432-520-0291
Fax Number	:	432-520-2723

Provider Business Practice Location Address
First Line	:	4519 N GARFIELD ST
Second Line	:	SUITE 15
City	:	MIDLAND
State	:	TX
Zip	:	79705-3415
Country	:	US
Telephone Number	:	432-520-0291
Fax Number	:	432-520-2723

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

Provider Enumeration Date	:	12/29/2005
Last Update Date	:	02/27/2013

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