Healthcare Provider Details

I. General information

NPI: 1154839397
Provider Name (Legal Business Name): TIMOTHY LEMERRILL WHITE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2018
Last Update Date: 10/26/2021
Certification Date: 10/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9982 SW 101ST AVE
GAINESVILLE FL
32608-6089
US

IV. Provider business mailing address

9982 SW 101ST AVE
GAINESVILLE FL
32608-6089
US

V. Phone/Fax

Practice location:
  • Phone: 352-363-4256
  • Fax:
Mailing address:
  • Phone: 352-363-4256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number117539
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: