Provider Demographics
NPI:1720316763
Name:VAN TASSELL, COURTNEY (CRNA)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:VAN TASSELL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:
Other - Last Name:BRADDOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:205 N EAST AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1753
Mailing Address - Country:US
Mailing Address - Phone:517-788-4800
Mailing Address - Fax:517-780-7352
Practice Address - Street 1:205 N EAST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1753
Practice Address - Country:US
Practice Address - Phone:517-788-4800
Practice Address - Fax:517-780-7352
Is Sole Proprietor?:No
Enumeration Date:2009-12-03
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704241423163W00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse