Provider Demographics
NPI:1689636540
Name:STITTSWORTH, DAVID L (CRNA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:L
Last Name:STITTSWORTH
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17713 E SHADOW LAKE RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-8136
Mailing Address - Country:US
Mailing Address - Phone:618-244-2336
Mailing Address - Fax:618-244-1993
Practice Address - Street 1:17713 E SHADOW LAKE RD
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-8136
Practice Address - Country:US
Practice Address - Phone:618-244-2336
Practice Address - Fax:618-244-1993
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209000982367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered