Healthcare Provider Details

I. General information

NPI: 1003675992
Provider Name (Legal Business Name): CARLY PROVAN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2024
Last Update Date: 03/14/2024
Certification Date: 03/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8000 STATE ROAD 64 E
BRADENTON FL
34212-7703
US

IV. Provider business mailing address

12912 USF HEALTH DRIVE
TAMPA FL
33612
US

V. Phone/Fax

Practice location:
  • Phone: 941-792-1404
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN9514153
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: