Provider Demographics
NPI:1235764218
Name:HARRIS, COURTNEY J (CRNA)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:J
Last Name:HARRIS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 N OAKCREST AVE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62522-1812
Mailing Address - Country:US
Mailing Address - Phone:314-616-5191
Mailing Address - Fax:
Practice Address - Street 1:1 SAINT ELIZABETH BLVD
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1099
Practice Address - Country:US
Practice Address - Phone:618-234-2120
Practice Address - Fax:618-641-5810
Is Sole Proprietor?:No
Enumeration Date:2020-03-10
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.020870367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered