Healthcare Provider Details

I. General information

NPI: 1356662944
Provider Name (Legal Business Name): JEANNINE CATHERINE HEISS WUNDERLICH CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2010
Last Update Date: 01/19/2021
Certification Date: 01/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6820 INTERNATIONAL CENTER BLVD
FORT MYERS FL
33912-7129
US

IV. Provider business mailing address

14013 CLEAR WATER LN
FORT MYERS FL
33907-8097
US

V. Phone/Fax

Practice location:
  • Phone: 239-360-8000
  • Fax:
Mailing address:
  • Phone: 239-281-4627
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP2811442
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: