Healthcare Provider Details

I. General information

NPI: 1144737339
Provider Name (Legal Business Name): JENNIFER MARIE COLEMAN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER MARIE MEDINA CRNA

II. Dates (important events)

Enumeration Date: 01/09/2018
Last Update Date: 05/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 N CENTRAL AVE STE 1600
PHOENIX AZ
85004-4633
US

IV. Provider business mailing address

3900 E BASELINE RD UNIT 153
PHOENIX AZ
85042-6380
US

V. Phone/Fax

Practice location:
  • Phone: 602-262-8900
  • Fax:
Mailing address:
  • Phone: 520-709-0050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA1461
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: