Provider Demographics
NPI:1770571648
Name:SMITH-LEX, SANDRA (CRNA)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:SMITH-LEX
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 1:800 EAST CARPENTER STREET
Mailing Address - Street 2:ROOM 2K64
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62769-0001
Mailing Address - Country:US
Mailing Address - Phone:217-525-5643
Mailing Address - Fax:217-544-2521
Practice Address - Street 1:800 EAST CARPENTER STREET
Practice Address - Street 2:ROOM 2K64
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62769-0001
Practice Address - Country:US
Practice Address - Phone:217-525-5643
Practice Address - Fax:217-544-2521
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041229268367500000X
IL209001446367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL041229268OtherIL STATE LICENSE #
IL031312OtherHEALTH ALLIANCE NUMBERS
IL209-005625OtherIL APN LICENSE #
IL45622OtherAANA#
IL45622OtherAANA#
ILCF2131Medicare ID - Type UnspecifiedMEDICARE RR GROUP #
IL794510Medicare ID - Type UnspecifiedMEDICARE GROUP #
IL430033968Medicare ID - Type UnspecifiedMCARERR
IL209-005625OtherIL APN LICENSE #
ILS04936Medicare UPIN