Provider Demographics
NPI:1245490275
Name:KUTZER MCMANUS, BREANN MARIE (CRNA)
Entity type:Individual
Prefix:
First Name:BREANN
Middle Name:MARIE
Last Name:KUTZER MCMANUS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:BREANN
Other - Middle Name:MARIE
Other - Last Name:KUTZER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:500 N NAPPANEE ST
Mailing Address - Street 2:SUITE 11-B
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-1503
Mailing Address - Country:US
Mailing Address - Phone:574-522-9922
Mailing Address - Fax:574-522-9926
Practice Address - Street 1:500 N NAPPANEE ST
Practice Address - Street 2:SUITE 11-B
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-1503
Practice Address - Country:US
Practice Address - Phone:574-522-9922
Practice Address - Fax:574-522-9926
Is Sole Proprietor?:No
Enumeration Date:2008-06-12
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28155028A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000569464OtherANTHEM
IN200922790Medicaid
IN145420GGMedicare PIN