Provider Demographics
NPI:1326387143
Name:CHAMPINE, JILLIAN MOURANIE (CRNA)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:MOURANIE
Last Name:CHAMPINE
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 1:130 TOWN CENTER DR STE 203
Mailing Address - Street 2:BEAUMONT PHYSICIAN PARTNERS PAYOR ENROLLMENT
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-1744
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2006 HOGBACK RD STE 5A
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-9750
Practice Address - Country:US
Practice Address - Phone:734-263-2417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-14
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704266732367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI430F364420OtherBCBSM
MI430F364420OtherBCBSM