Healthcare Provider Details

I. General information

NPI: 1316991433
Provider Name (Legal Business Name): LISA JENNIFER BLAIR CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA JENNIFER MORENO

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 06/17/2025
Certification Date: 06/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 MAIN ST
DUNEDIN FL
34698-5848
US

IV. Provider business mailing address

PO BOX 1074
DUNEDIN FL
34697-1074
US

V. Phone/Fax

Practice location:
  • Phone: 727-734-6916
  • Fax: 727-734-4516
Mailing address:
  • Phone: 727-376-3065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR26329
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN102078
License Number StateWV
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP9166030
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: