Provider Demographics
NPI:1730728684
Name:DEFRIES, SALLY JUNG (CRNA)
Entity type:Individual
Prefix:MISS
First Name:SALLY
Middle Name:JUNG
Last Name:DEFRIES
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 1:1500 SCENIC DR APT 305
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78703-2050
Mailing Address - Country:US
Mailing Address - Phone:512-589-4899
Mailing Address - Fax:
Practice Address - Street 1:12221 N MOPAC EXPY
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758-2401
Practice Address - Country:US
Practice Address - Phone:512-901-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-24
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX832594163W00000X
TXAP144692367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse