Provider Demographics
NPI:1104003326
Name:CANFIELD, CARLENE M (CRNA)
Entity Type:Individual
Prefix:
First Name:CARLENE
Middle Name:M
Last Name:CANFIELD
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6313
Mailing Address - Country:US
Mailing Address - Phone:208-525-2090
Mailing Address - Fax:208-525-2662
Practice Address - Street 1:1601 E 17TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6313
Practice Address - Country:US
Practice Address - Phone:208-525-2090
Practice Address - Fax:208-525-2662
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-30
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN-15497367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID008644600Medicaid
IDA0348OtherBLUE CROSS
ID1600297Medicare UPIN