Basic Information
| Provider Information | |||||||||
| NPI: | 1730728684 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEFRIES | ||||||||
| FirstName: | SALLY | ||||||||
| MiddleName: | JUNG | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 SCENIC DR APT 305 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787032050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5125894899 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 12221 N MOPAC EXPY | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787582401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5129011000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/24/2019 | ||||||||
| LastUpdateDate: | 06/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 832594 | TX | N | Nursing Service Providers | Registered Nurse | 367500000X | AP144692 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.