Healthcare Provider Details

I. General information

NPI: 1609037886
Provider Name (Legal Business Name): JAIME M POLT CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2008
Last Update Date: 11/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 W ERIE ST STE 203
PAINESVILLE OH
44077-3274
US

IV. Provider business mailing address

40 W ERIE ST STE 203
PAINESVILLE OH
44077-3274
US

V. Phone/Fax

Practice location:
  • Phone: 440-350-0832
  • Fax: 440-354-7420
Mailing address:
  • Phone: 440-350-0832
  • Fax: 440-354-7420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number80373
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: