Provider Demographics
NPI:1013256916
Name:DAHL, JEANNINE (CRNA)
Entity Type:Individual
Prefix:
First Name:JEANNINE
Middle Name:
Last Name:DAHL
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 1:31923 BELLA VISTA DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-2827
Mailing Address - Country:US
Mailing Address - Phone:734-673-5097
Mailing Address - Fax:
Practice Address - Street 1:31923 BELLA VISTA DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-2827
Practice Address - Country:US
Practice Address - Phone:734-673-5097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-12
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704225099367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered