Provider Demographics
NPI:1619458114
Name:KORNMUELLER, RUTH ONITA (CRNA)
Entity Type:Individual
Prefix:
First Name:RUTH
Middle Name:ONITA
Last Name:KORNMUELLER
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 1:2537 W STATE ST STE 200
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-2200
Mailing Address - Country:US
Mailing Address - Phone:208-336-0895
Mailing Address - Fax:208-338-1796
Practice Address - Street 1:190 E BANNOCK ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6241
Practice Address - Country:US
Practice Address - Phone:208-381-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-23
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID59306367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered