MEDICARE: MRS. DANA STEVENSON 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	NA10504	OH
2	367500000X	Certified Registered Nurse Anesthetist	6062A	KY
3	367500000X	Certified Registered Nurse Anesthetist	11865	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4120865	OTHER	TN	BCBS

General Provider Information

NPI Number	:	1487628400
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DANA STEVENSON CRNA

Provider Business Mailing Address
First Line	:	3075 VICTORIA AVE
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45208-1505
Country	:	US
Telephone Number	:	615-772-8985
Fax Number	:

Provider Business Practice Location Address
First Line	:	3075 VICTORIA AVE
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45208-1505
Country	:	US
Telephone Number	:	615-772-8985
Fax Number	:

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

Provider Enumeration Date	:	02/15/2006
Last Update Date	:	03/02/2016

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