Healthcare Provider Details

I. General information

NPI: 1285661116
Provider Name (Legal Business Name): JESSICA MILBURN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 07/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 W SHERMAN AVE
VINELAND NJ
08360-6912
US

IV. Provider business mailing address

PO BOX 650782
DALLAS TX
75265-0782
US

V. Phone/Fax

Practice location:
  • Phone: 856-641-8000
  • Fax: 856-641-7668
Mailing address:
  • Phone: 302-733-0705
  • Fax: 302-733-0854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number26NJ00240400
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number26NO11582100
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN348539L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: