Healthcare Provider Details

I. General information

NPI: 1104275874
Provider Name (Legal Business Name): JESSICA WILLIS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2016
Last Update Date: 12/20/2024
Certification Date: 12/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 TEMPLE DR
SANFORD FL
32771
US

IV. Provider business mailing address

108 TEMPLE DR
SANFORD FL
32771
US

V. Phone/Fax

Practice location:
  • Phone: 407-314-6999
  • Fax:
Mailing address:
  • Phone: 407-314-6999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP9305358
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: