Healthcare Provider Details

I. General information

NPI: 1770885717
Provider Name (Legal Business Name): JACQUELINE R RUSCH CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACQUELINE R BERTMEYER

II. Dates (important events)

Enumeration Date: 11/24/2010
Last Update Date: 04/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 HICKORY ST
MELBOURNE FL
32901-3224
US

IV. Provider business mailing address

PO BOX 2400
MELBOURNE FL
32902-2400
US

V. Phone/Fax

Practice location:
  • Phone: 321-837-3820
  • Fax:
Mailing address:
  • Phone: 321-837-3820
  • Fax: 603-893-8886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCOA.11919-NA
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP9361702
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: