Healthcare Provider Details

I. General information

NPI: 1225131360
Provider Name (Legal Business Name): MARY VATTAMATTAM CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 PINELLAS ST
CLEARWATER FL
33756-3804
US

IV. Provider business mailing address

300 JEFFORDS ST SUITE B
CLEARWATER FL
33756-3810
US

V. Phone/Fax

Practice location:
  • Phone: 727-462-7000
  • Fax:
Mailing address:
  • Phone: 727-441-1524
  • Fax: 727-443-4206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP765932
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: