Healthcare Provider Details

I. General information

NPI: 1104890730
Provider Name (Legal Business Name): VICKI ANGELA LOBRACCO CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 06/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3541 SW BIMINI CIR N
PALM CITY FL
34990-1301
US

IV. Provider business mailing address

3541 SW BIMINI CIR N
PALM CITY FL
34990-1301
US

V. Phone/Fax

Practice location:
  • Phone: 786-295-5520
  • Fax:
Mailing address:
  • Phone: 786-295-5520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP2574102
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: