Provider Demographics
NPI:1457418071
Name:ANNICELLI, SUSAN (CRNA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:ANNICELLI
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 1:1518 GRIERSON AVE
Mailing Address - Street 2:
Mailing Address - City:FORT HUACHUCA
Mailing Address - State:AZ
Mailing Address - Zip Code:85613
Mailing Address - Country:US
Mailing Address - Phone:520-533-9026
Mailing Address - Fax:
Practice Address - Street 1:USA MEDDAC, RWBAHC
Practice Address - Street 2:2240E. WINROW AVE
Practice Address - City:FORT HUACHUCA
Practice Address - State:AZ
Practice Address - Zip Code:85613-7079
Practice Address - Country:US
Practice Address - Phone:520-533-9026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC108867367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered