Healthcare Provider Details

I. General information

NPI: 1972875888
Provider Name (Legal Business Name): ADA COUNTESS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2012
Last Update Date: 08/10/2020
Certification Date: 08/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 NW 12TH AVE
MIAMI FL
33136-1005
US

IV. Provider business mailing address

1611 NW 12TH AVE
MIAMI FL
33136-1005
US

V. Phone/Fax

Practice location:
  • Phone: 305-243-6358
  • Fax: 305-243-3300
Mailing address:
  • Phone: 305-243-6358
  • Fax: 305-243-3300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP9225721
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: