Healthcare Provider Details

I. General information

NPI: 1861421216
Provider Name (Legal Business Name): THEA CRIST CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 03/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7700 W SUNRISE BLVD C/O TIVA HEALTHCARE
PLANTATION FL
33322-4113
US

IV. Provider business mailing address

7700 W SUNRISE BLVD C/O TIVA HEALTHCARE
PLANTATION FL
33322-4113
US

V. Phone/Fax

Practice location:
  • Phone: 954-739-7009
  • Fax:
Mailing address:
  • Phone: 954-739-7009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP 9182057
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRNA83311
License Number StateME
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209765
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: