Provider Demographics
NPI:1063956035
Name:CARROLL, KRISTAIN DRU (CRNA)
Entity type:Individual
Prefix:
First Name:KRISTAIN
Middle Name:DRU
Last Name:CARROLL
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 1:301 HILLVIEW ST
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-6329
Mailing Address - Country:US
Mailing Address - Phone:573-275-0214
Mailing Address - Fax:
Practice Address - Street 1:1008 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801
Practice Address - Country:US
Practice Address - Phone:573-275-0214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-11
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011022765163W00000X
MO2017012413367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse