Provider Demographics
NPI:1982766143
Name:PROVOST, RHONDA MARIE (CRNA)
Entity Type:Individual
Prefix:MS
First Name:RHONDA
Middle Name:MARIE
Last Name:PROVOST
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 1:7050 GIUSTI RD
Mailing Address - Street 2:
Mailing Address - City:FORESTVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95436-9637
Mailing Address - Country:US
Mailing Address - Phone:707-478-9798
Mailing Address - Fax:
Practice Address - Street 1:10 WOODLAND RD
Practice Address - Street 2:
Practice Address - City:SAINT HELENA
Practice Address - State:CA
Practice Address - Zip Code:94574
Practice Address - Country:US
Practice Address - Phone:707-963-3611
Practice Address - Fax:707-887-0320
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN305247367500000X
MARN103162367500000X
CANA170367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ14451Medicaid