Healthcare Provider Details

I. General information

NPI: 1265187819
Provider Name (Legal Business Name): JACQUELINE MULDER CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2022
Last Update Date: 03/19/2025
Certification Date: 03/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 6TH AVE S
SAINT PETERSBURG FL
33701-4634
US

IV. Provider business mailing address

2119 CATALONIA WAY S
SAINT PETERSBURG FL
33712-4159
US

V. Phone/Fax

Practice location:
  • Phone: 727-898-7451
  • Fax:
Mailing address:
  • Phone: 616-299-5485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN9448689
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704311252
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN11019591
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: