Provider Demographics
NPI:1063897908
Name:KRIES, SARAH NICOLE (CRNA)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:NICOLE
Last Name:KRIES
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 1:1239 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-3175
Mailing Address - Country:US
Mailing Address - Phone:618-942-2171
Mailing Address - Fax:618-351-4919
Practice Address - Street 1:201 S 14TH ST
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-3631
Practice Address - Country:US
Practice Address - Phone:618-942-2171
Practice Address - Fax:618-351-4919
Is Sole Proprietor?:No
Enumeration Date:2015-07-21
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041369893163W00000X
IL209013021367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214881OtherMULTI SPECIALTY GROUP