Healthcare Provider Details

I. General information

NPI: 1447600184
Provider Name (Legal Business Name): ERICA HUMPHREY POWELL CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ERICA MICHELLE HUMPHREY

II. Dates (important events)

Enumeration Date: 06/14/2016
Last Update Date: 07/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 WATERMAN WAY
TAVARES FL
32778-5266
US

IV. Provider business mailing address

5746 ANSLEY WAY
MOUNT DORA FL
32757-8002
US

V. Phone/Fax

Practice location:
  • Phone: 321-422-7156
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number110372
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number9366265
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: