Healthcare Provider Details

I. General information

NPI: 1407150071
Provider Name (Legal Business Name): ANDREA BAUER BANTA CRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2010
Last Update Date: 11/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1613 HARRISON PKWY
SUNRISE FL
33323-2896
US

IV. Provider business mailing address

11120 SW 58TH CT
PINECREST FL
33156-5015
US

V. Phone/Fax

Practice location:
  • Phone: 180-043-7267
  • Fax:
Mailing address:
  • Phone: 305-794-9016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9222380
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP9222380
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: