Healthcare Provider Details

I. General information

NPI: 1255365680
Provider Name (Legal Business Name): KATHLEEN FLITCRAFT CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHLEEN M. SHERON FLITCRAFT RN

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 06/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 W. FRONT ST.
ELMER NJ
08318-2101
US

IV. Provider business mailing address

PO BOX 650782
DALLAS TX
75265-0782
US

V. Phone/Fax

Practice location:
  • Phone: 856-363-1000
  • Fax: 856-358-0994
Mailing address:
  • Phone: 302-733-0806
  • Fax: 302-733-0854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberL1-0028494
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number26NO11053100
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number26NJ00238000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: