Provider Demographics
NPI:1487033114
Name:BROWN, DIANA BUSJRA (CRNA)
Entity Type:Individual
Prefix:MS
First Name:DIANA
Middle Name:BUSJRA
Last Name:BROWN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:
Other - Last Name:BUSJRA BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:751 SAPPINGTON BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:MO
Mailing Address - Zip Code:63080-2354
Mailing Address - Country:US
Mailing Address - Phone:573-468-4186
Mailing Address - Fax:
Practice Address - Street 1:751 SAPPINGTON BRIDGE RD
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:MO
Practice Address - Zip Code:63080-2354
Practice Address - Country:US
Practice Address - Phone:573-468-4186
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-27
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015027444367500000X
MO2009029775163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO910025751Medicaid
ILENROLLEDMedicaid