Provider Demographics
NPI:1699773028
Name:DEGIDIO, RAENALLE J (CRNA)
Entity type:Individual
Prefix:MS
First Name:RAENALLE
Middle Name:J
Last Name:DEGIDIO
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 1:14123 SO. WINSTON AVE.
Mailing Address - Street 2:
Mailing Address - City:BIXBY
Mailing Address - State:OK
Mailing Address - Zip Code:74008-3775
Mailing Address - Country:US
Mailing Address - Phone:918-366-0636
Mailing Address - Fax:918-366-0636
Practice Address - Street 1:14123 S WINSTON AVE
Practice Address - Street 2:
Practice Address - City:BIXBY
Practice Address - State:OK
Practice Address - Zip Code:74008-3775
Practice Address - Country:US
Practice Address - Phone:918-366-0636
Practice Address - Fax:918-366-0636
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0034249163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse