Healthcare Provider Details

I. General information

NPI: 1174922769
Provider Name (Legal Business Name): JENNIFER KUNDRAT CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2014
Last Update Date: 12/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1671 N CLYDE MORRIS BLVD SUITE 100
DAYTONA BEACH FL
32117-5590
US

IV. Provider business mailing address

1671 N CLYDE MORRIS BLVD SUITE 100
DAYTONA BEACH FL
32117-5590
US

V. Phone/Fax

Practice location:
  • Phone: 386-274-2977
  • Fax: 386-274-2997
Mailing address:
  • Phone: 386-274-2977
  • Fax: 386-274-2997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberARNP9438010
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberSP014119
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: