Provider Demographics
NPI:1124135629
Name:GENEREUX, HEIDI (CRNA)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:GENEREUX
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:PO BOX 1296
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46581-1296
Mailing Address - Country:US
Mailing Address - Phone:574-268-9640
Mailing Address - Fax:574-268-0684
Practice Address - Street 1:2400 ST FRANCIS DR
Practice Address - Street 2:
Practice Address - City:BRECKENRIDGE
Practice Address - State:MN
Practice Address - Zip Code:56520-1025
Practice Address - Country:US
Practice Address - Phone:218-643-3000
Practice Address - Fax:574-268-0684
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 095825 9367500000X
NDR20219367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN430051818OtherPALMETTO GBA - RAILROAD MEDICARE
ND12110Medicaid
MN149842800Medicaid
ND430051818OtherPALMETTA GBA - RAILROAD MEDICARE
ND12110Medicaid
MN430051818OtherPALMETTO GBA - RAILROAD MEDICARE