Provider Demographics
NPI:1265072433
Name:CONRAD, JENNIFER VACCARO (CRNA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:VACCARO
Last Name:CONRAD
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LYNE
Other - Last Name:VACCARO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:488 WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26501-3938
Mailing Address - Country:US
Mailing Address - Phone:716-499-6229
Mailing Address - Fax:
Practice Address - Street 1:3500 VICTORIA STREET SCHOOL OF ANESTHESIA
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15261-0001
Practice Address - Country:US
Practice Address - Phone:412-624-4586
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-15
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV94111163WC0200X
PARN714741163WC0200X
WV111907367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine