Provider Demographics
NPI:1629361639
Name:JENSEN, KATIE SULLIVAN (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:SULLIVAN
Last Name:JENSEN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MISS
Other - First Name:KATIE
Other - Middle Name:GAYLE
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:409 S 2ND ST
Mailing Address - Street 2:SUITE 2F
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17104-1612
Mailing Address - Country:US
Mailing Address - Phone:717-782-3282
Mailing Address - Fax:717-231-8964
Practice Address - Street 1:111 S FRONT ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17101-2010
Practice Address - Country:US
Practice Address - Phone:717-782-5118
Practice Address - Fax:717-782-5854
Is Sole Proprietor?:No
Enumeration Date:2011-05-24
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN592667163W00000X, 367500000X
WI174761-30163W00000X
MDR162842367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102912432Medicaid
PA352416Medicare PIN