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General NPI Number Information
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NPI Number | 1679072003
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Entity Type | Individual
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Provider Name | JENNIFER KATE LAURENCE CRNA
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Gender | Female
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Dates
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Enumeration Date | 02/12/2018
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Last Update Date | 04/30/2020
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Provider Practice Location Address
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Address Line | 1400 8TH AVE
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City | FORT WORTH
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State | TX
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Zip | 76104-4110
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Country | US
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Telephone | 214-287-9039
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 840853
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City | DALLAS
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State | TX
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Zip | 75284-0853
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Country | US
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Telephone | 972-233-1999
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Fax | 972-233-3666
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | AP136471
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License Number State | TX
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