Basic Information
| Provider Information | |||||||||
| NPI: | 1518931344 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PROCTOR | ||||||||
| FirstName: | ANNETTE | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 268 | ||||||||
| Address2: | |||||||||
| City: | BOUNTIFUL | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840110268 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012962113 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2055 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | TOOELE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4358433600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2006 | ||||||||
| LastUpdateDate: | 03/02/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | R158002-4 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 413162200 | 05 | MN | MEDICAID |