Provider Demographics
NPI:1588651103
Name:LILIENTHAL, PATRICIA ROSE (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:ROSE
Last Name:LILIENTHAL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:ROSE
Other - Last Name:NURRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:200 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:319-356-2633
Mailing Address - Fax:319-356-2940
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1009
Practice Address - Country:US
Practice Address - Phone:319-356-2633
Practice Address - Fax:319-356-2940
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAD056412367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0146753Medicaid
IA56624OtherWELLMARK BCBS
R30318Medicare UPIN
IA56624OtherWELLMARK BCBS
IA0146753Medicaid