Provider Demographics
NPI:1376531244
Name:SCOVILLE, ROYCEANNE (CRNA)
Entity Type:Individual
Prefix:
First Name:ROYCEANNE
Middle Name:
Last Name:SCOVILLE
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 1:800 EAST CARPENTER STREET
Mailing Address - Street 2:ROOM 2K64
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62769-0001
Mailing Address - Country:US
Mailing Address - Phone:217-525-5643
Mailing Address - Fax:217-544-2521
Practice Address - Street 1:800 EAST CARPENTER STREET
Practice Address - Street 2:ROOM 2K64
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62769-0001
Practice Address - Country:US
Practice Address - Phone:217-525-5643
Practice Address - Fax:217-544-2521
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209002903367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL041206854OtherIL STATE LICENSE #
IL069877OtherHEALTH ALLIANCE NUMBERS
IL0841504038OtherBCBS OF ILLINOIS
IL209-005626OtherIL APN LICENSE #
IL52339OtherAANA#
ILP35451Medicare UPIN
IL0841504038OtherBCBS OF ILLINOIS
IL209-005626OtherIL APN LICENSE #
IL430063874Medicare ID - Type UnspecifiedMCARERR
IL768130Medicare ID - Type UnspecifiedMEDICARE PART B