Provider Demographics
NPI:1205369832
Name:LAKE SUPERIOR NURSE ANESTHESIA
Entity Type:Organization
Organization Name:LAKE SUPERIOR NURSE ANESTHESIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:STONE
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:802-989-2208
Mailing Address - Street 1:PO BOX 281
Mailing Address - Street 2:
Mailing Address - City:UNDERHILL
Mailing Address - State:VT
Mailing Address - Zip Code:05489-0281
Mailing Address - Country:US
Mailing Address - Phone:802-497-3371
Mailing Address - Fax:
Practice Address - Street 1:105 WESTVIEW RD STE 302
Practice Address - Street 2:
Practice Address - City:COLCHESTER
Practice Address - State:VT
Practice Address - Zip Code:05446-8025
Practice Address - Country:US
Practice Address - Phone:802-497-3371
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-11
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty