1104006386 NPI number — DANETTE LYNNE CROASTON CRNA

Table of content: DANETTE LYNNE CROASTON CRNA (NPI 1104006386)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104006386 NPI number — DANETTE LYNNE CROASTON CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CROASTON
Provider First Name:
DANETTE
Provider Middle Name:
LYNNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CABE
Provider Other First Name:
DANETTE
Provider Other Middle Name:
LYNNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRNA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1104006386
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/18/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
111 LONE PINE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MASONTOWN
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26542-8605
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-376-6557
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 LONE PINE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MASONTOWN
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26542-8605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-376-6557
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  61484 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3810010505 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2830735 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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