Provider Demographics
NPI:1578672150
Name:ADDIS, JULIE ANNE (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:ANNE
Last Name:ADDIS
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 1:17501 GENERATIONS DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1589
Mailing Address - Country:US
Mailing Address - Phone:574-234-0049
Mailing Address - Fax:574-234-0053
Practice Address - Street 1:53830 GENERATIONS DR
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1543
Practice Address - Country:US
Practice Address - Phone:574-271-0893
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN051170367500000X
IN28182698A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered