Provider Demographics
NPI:1356886832
Name:HENRIE, JEREMY (CRNA)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:HENRIE
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 1:10660 S REMBRANDT LN
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-5224
Mailing Address - Country:US
Mailing Address - Phone:804-594-2622
Mailing Address - Fax:804-594-0915
Practice Address - Street 1:10660 S REMBRANDT LN
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-5224
Practice Address - Country:US
Practice Address - Phone:801-808-1647
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-20
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8380193-3102367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered