Healthcare Provider Details

I. General information

NPI: 1114341468
Provider Name (Legal Business Name): CAROLINE PEMBROOKE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CAROLINE WERNER CRNA

II. Dates (important events)

Enumeration Date: 02/06/2014
Last Update Date: 01/22/2024
Certification Date: 01/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7503 SURRATTS RD
CLINTON MD
20735-3358
US

IV. Provider business mailing address

7503 SURRATTS RD
CLINTON MD
20735-3358
US

V. Phone/Fax

Practice location:
  • Phone: 855-633-0205
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR174315
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR174315
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN628637
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: