Provider Demographics
NPI:1750317467
Name:STEFEK, JAQUELINE R (CRNA)
Entity Type:Individual
Prefix:
First Name:JAQUELINE
Middle Name:R
Last Name:STEFEK
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 1:4646 S OAK CT
Mailing Address - Street 2:
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80127-1066
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3704 FAIRFAX AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87402-4578
Practice Address - Country:US
Practice Address - Phone:303-596-0257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO163304367500000X
NMCRNA-01176367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08259861Medicaid
UT1750317467Medicaid
AZ685594Medicaid
NM38278251Medicaid
CO90580834Medicaid
CO08259861Medicaid
AZ685594Medicaid