Healthcare Provider Details

I. General information

NPI: 1962578534
Provider Name (Legal Business Name): ROBERT NATHANIEL LADD CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 01/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NH JACKSONVILLE 2080 CHILD ST
JACKSONVILLE FL
32214-0001
US

IV. Provider business mailing address

9072 REDTAIL DR
JACKSONVILLE FL
32222-2836
US

V. Phone/Fax

Practice location:
  • Phone: 904-542-7632
  • Fax:
Mailing address:
  • Phone: 803-210-7741
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number43256
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: