Provider Demographics
NPI:1871503748
Name:WADE, KRISTELL MARIE (CRNA)
Entity Type:Individual
Prefix:
First Name:KRISTELL
Middle Name:MARIE
Last Name:WADE
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 1:79360 WADE GULCH LANE
Mailing Address - Street 2:
Mailing Address - City:LOSTINE
Mailing Address - State:OR
Mailing Address - Zip Code:97857
Mailing Address - Country:US
Mailing Address - Phone:541-263-1465
Mailing Address - Fax:
Practice Address - Street 1:604 MEDICAL PARKWAY
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:OR
Practice Address - Zip Code:97828
Practice Address - Country:US
Practice Address - Phone:541-426-5306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR163W00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Not Answered367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered