Basic Information
| Provider Information | |||||||||
| NPI: | 1104841105 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SNOWDEN | ||||||||
| FirstName: | JUSTIN | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 925 SHERWOOD DR | ||||||||
| Address2: | |||||||||
| City: | LAKE BLUFF | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600442203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3183238887 | ||||||||
| FaxNumber: | 8476152858 | ||||||||
| Practice Location | |||||||||
| Address1: | 503 MCMILLAN RD | ||||||||
| Address2: | |||||||||
| City: | WEST MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712915327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3183238887 | ||||||||
| FaxNumber: | 8476152858 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 11/30/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN085475 | LA | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 1109789 | 05 | LA | MEDICAID |