Healthcare Provider Details

I. General information

NPI: 1275655987
Provider Name (Legal Business Name): MARY A JUSTYN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 11/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 TEBEAU ST
WAYCROSS GA
31501-6357
US

IV. Provider business mailing address

1888 GARDENIA ST
FERNANDINA BEACH FL
32034-1908
US

V. Phone/Fax

Practice location:
  • Phone: 912-338-6511
  • Fax: 912-338-6512
Mailing address:
  • Phone: 904-261-7115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP9183190
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: