Healthcare Provider Details

I. General information

NPI: 1801291372
Provider Name (Legal Business Name): JENNIFER SLADE ARCILA CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2014
Last Update Date: 06/27/2022
Certification Date: 12/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5759 CEDAR LN
COLUMBIA MD
21044-2912
US

IV. Provider business mailing address

6201 GREENLEIGH AVE
MIDDLE RIVER MD
21220-2004
US

V. Phone/Fax

Practice location:
  • Phone: 410-740-7795
  • Fax:
Mailing address:
  • Phone: 410-933-6423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR231009
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number634913
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR231009
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: