Provider Demographics
NPI:1477509057
Name:JANICEK, DENISE LOUISE (CRNA)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:LOUISE
Last Name:JANICEK
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 1:338 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6207
Mailing Address - Country:US
Mailing Address - Phone:208-336-0895
Mailing Address - Fax:208-338-1796
Practice Address - Street 1:338 E BANNOCK ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6207
Practice Address - Country:US
Practice Address - Phone:208-336-0895
Practice Address - Fax:208-338-1796
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN15758163W00000X
IDRNA542367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806480500Medicaid
ID430079011OtherRAILROAD MEDICARE
ID1603728Medicare PIN