Healthcare Provider Details

I. General information

NPI: 1306362173
Provider Name (Legal Business Name): JULYSSA COLON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2017
Last Update Date: 10/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 LAKELAND HILLS BLVD
LAKELAND FL
33805-3019
US

IV. Provider business mailing address

3300 BERWICK LN
LAKELAND FL
33810-2849
US

V. Phone/Fax

Practice location:
  • Phone: 863-680-7380
  • Fax:
Mailing address:
  • Phone: 787-975-6400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number9458580
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: