Provider Demographics
NPI:1407803265
Name:BOETEL, EILEEN (CRNA)
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:
Last Name:BOETEL
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 1:552 FLEETWOOD DR N
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46385-6806
Mailing Address - Country:US
Mailing Address - Phone:219-929-6982
Mailing Address - Fax:219-464-7221
Practice Address - Street 1:18221 TORRENCE AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:IL
Practice Address - Zip Code:60438-2870
Practice Address - Country:US
Practice Address - Phone:708-895-9450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28078166A367500000X
IL209.005883367500000X
WI17767330367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200542180Medicaid
IN000000610944OtherANTHEM PROVIDER NUMBER
IN815500X3Medicare PIN
INP00732704Medicare PIN
IN200542180Medicaid