Healthcare Provider Details

I. General information

NPI: 1891091971
Provider Name (Legal Business Name): EMILIE M HENDERSON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: EMILIE M WYBLE

II. Dates (important events)

Enumeration Date: 02/07/2011
Last Update Date: 06/04/2023
Certification Date: 06/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 S 18TH ST
FERNANDINA BEACH FL
32034-1902
US

IV. Provider business mailing address

96022 OCEAN BREEZE WAY
FERNANDINA BEACH FL
32034-8489
US

V. Phone/Fax

Practice location:
  • Phone: 770-906-0029
  • Fax:
Mailing address:
  • Phone: 770-906-0029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number9418490
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: