MEDICARE: LISSA BLAHNIK 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	209005387	IL

General Provider Information

NPI Number	:	1669503314
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISSA BLAHNIK CRNA

Provider Business Mailing Address
First Line	:	510 W ERIE ST
Second Line	:	UNIT 1303
City	:	CHICAGO
State	:	IL
Zip	:	60610-6456
Country	:	US
Telephone Number	:	312-440-0553
Fax Number	:

Provider Business Practice Location Address
First Line	:	510 W ERIE ST
Second Line	:	UNIT 1303
City	:	CHICAGO
State	:	IL
Zip	:	60610-6456
Country	:	US
Telephone Number	:	312-440-0553
Fax Number	:

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

Provider Enumeration Date	:	03/07/2007
Last Update Date	:	07/08/2007

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