Provider Demographics
NPI:1922257211
Name:STUFFLE, JERRY LEE (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:LEE
Last Name:STUFFLE
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 1:8673 CALHOUN PL
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-7713
Mailing Address - Country:US
Mailing Address - Phone:219-365-7954
Mailing Address - Fax:
Practice Address - Street 1:8673 CALHOUN PL
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-7713
Practice Address - Country:US
Practice Address - Phone:219-365-7954
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-11
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28121816A367500000X
IL041.313724367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered