Provider Demographics
NPI:1851605653
Name:DELARUELLE, JENNIFER LYNN (CRNA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:DELARUELLE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:SANDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:W351N5434 LAKE DR
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-2516
Mailing Address - Country:US
Mailing Address - Phone:920-309-0086
Mailing Address - Fax:
Practice Address - Street 1:1032 E SUMNER ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:WI
Practice Address - Zip Code:53027-1608
Practice Address - Country:US
Practice Address - Phone:262-670-7260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-04
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI131677-30367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered