Healthcare Provider Details

I. General information

NPI: 1083005532
Provider Name (Legal Business Name): NICOLE MARIE DIBELLA CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE MARIE GULA CRNA

II. Dates (important events)

Enumeration Date: 02/05/2015
Last Update Date: 02/27/2020
Certification Date: 02/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11375 CORTEZ BLVD
BROOKSVILLE FL
34613-5409
US

IV. Provider business mailing address

7111 FAIRWAY DR STE 450
PALM BEACH GARDENS FL
33418-4200
US

V. Phone/Fax

Practice location:
  • Phone: 352-596-6632
  • Fax:
Mailing address:
  • Phone: 561-623-2001
  • Fax: 865-347-5154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP9270729
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: