Healthcare Provider Details

I. General information

NPI: 1053413641
Provider Name (Legal Business Name): JENNIFER D MCCLAIN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 01/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 KINGSLEY LN
NORFOLK VA
23505-4602
US

IV. Provider business mailing address

PO BOX 198424
ATLANTA GA
30384-8424
US

V. Phone/Fax

Practice location:
  • Phone: 757-889-5109
  • Fax:
Mailing address:
  • Phone: 757-889-5109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0024165628
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: