Healthcare Provider Details

I. General information

NPI: 1285656355
Provider Name (Legal Business Name): MARY KAY O'TOOLE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 MEDICAL PARK DR STE 101
MELBOURNE FL
32901-3246
US

IV. Provider business mailing address

3162 BEACH WINDS CT
MELBOURNE BEACH FL
32951-3014
US

V. Phone/Fax

Practice location:
  • Phone: 321-729-9493
  • Fax:
Mailing address:
  • Phone: 321-729-9493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP 9175524
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: