Provider Demographics
NPI:1477935112
Name:BACH, ANNMARIE (CRNA)
Entity Type:Individual
Prefix:
First Name:ANNMARIE
Middle Name:
Last Name:BACH
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 1:2831 RYAN DR
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-2633
Mailing Address - Country:US
Mailing Address - Phone:815-717-6621
Mailing Address - Fax:
Practice Address - Street 1:19627 S LA GRANGE RD
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-9360
Practice Address - Country:US
Practice Address - Phone:708-326-1671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-18
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28211331A163W00000X
IL041310711163W00000X
IL209013115367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse