Healthcare Provider Details

I. General information

NPI: 1881702074
Provider Name (Legal Business Name): JOHN T HIMEBAUGH CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2006
Last Update Date: 07/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 SE TIFFANY AVE
PORT ST LUCIE FL
34952-7521
US

IV. Provider business mailing address

PO BOX 7520
PORT ST LUCIE FL
34985-7520
US

V. Phone/Fax

Practice location:
  • Phone: 772-335-2471
  • Fax: 772-335-2497
Mailing address:
  • Phone: 772-335-2471
  • Fax: 772-335-2497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP1219122
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: