Healthcare Provider Details

I. General information

NPI: 1093444176
Provider Name (Legal Business Name): ANNA GRACE BLACKMAN GREEN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2022
Last Update Date: 06/06/2022
Certification Date: 06/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

449 W 23RD ST
PANAMA CITY FL
32405-4507
US

IV. Provider business mailing address

22944 ANN MILLER RD
PANAMA CITY BEACH FL
32413-1196
US

V. Phone/Fax

Practice location:
  • Phone: 850-769-8341
  • Fax:
Mailing address:
  • Phone: 205-807-9612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1-156236
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number137066
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: