Healthcare Provider Details

I. General information

NPI: 1689676405
Provider Name (Legal Business Name): JANIE M. WEEKS-LONG CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 12/04/2020
Certification Date: 12/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

862 THE MASTERS BLVD
SHALIMAR FL
32579-1664
US

IV. Provider business mailing address

862 THE MASTERS BLVD
SHALIMAR FL
32579-1664
US

V. Phone/Fax

Practice location:
  • Phone: 850-651-6984
  • Fax:
Mailing address:
  • Phone: 850-651-6984
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN2299249
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1281222
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: