Provider Demographics
NPI:1205984366
Name:KRISTIANSEN, STANLEY ANSEL (CRNA)
Entity type:Individual
Prefix:
First Name:STANLEY
Middle Name:ANSEL
Last Name:KRISTIANSEN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:MR
Other - First Name:STANLEY
Other - Middle Name:ANSEL
Other - Last Name:KRISTIANSEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 38
Mailing Address - Street 2:
Mailing Address - City:CORYDON
Mailing Address - State:IN
Mailing Address - Zip Code:47112-0038
Mailing Address - Country:US
Mailing Address - Phone:812-738-4251
Mailing Address - Fax:
Practice Address - Street 1:3249 OAK PARK AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-3429
Practice Address - Country:US
Practice Address - Phone:708-783-3013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3006664367500000X
IL209027161367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN237042323OtherCOMMERCIAL
IN237042323OtherCOMMERCIAL