Healthcare Provider Details

I. General information

NPI: 1396483459
Provider Name (Legal Business Name): KACI JO BOLLINGER CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2022
Last Update Date: 02/03/2025
Certification Date: 02/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 6TH ST S
ST PETERSBURG FL
33701-4891
US

IV. Provider business mailing address

701 6TH ST S
ST PETERSBURG FL
33701-4891
US

V. Phone/Fax

Practice location:
  • Phone: 321-841-2335
  • Fax:
Mailing address:
  • Phone: 321-841-2335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number11019663
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: