Healthcare Provider Details

I. General information

NPI: 1700862844
Provider Name (Legal Business Name): TERESE MARY WARNER CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 11/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1590 CENTURY ACRES LANE
SAINT JOHNS FL
32259
US

IV. Provider business mailing address

1590 CENTURY ACRES LANE
SAINT JOHNS FL
32259
US

V. Phone/Fax

Practice location:
  • Phone: 904-710-6811
  • Fax:
Mailing address:
  • Phone: 904-710-6811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number543487
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number9262060
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number123895
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: