MEDICARE: MRS. JUDITH CAROL PERREAULT CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	ARNP 9182205	FL

General Provider Information

NPI Number	:	1033158118
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JUDITH CAROL PERREAULT CRNA

Provider Business Mailing Address
First Line	:	16806 INNOCENTE AVE
Second Line	:
City	:	PANAMA CITY BEACH
State	:	FL
Zip	:	32413-2318
Country	:	US
Telephone Number	:	850-234-1868
Fax Number	:	850-234-1468

Provider Business Practice Location Address
First Line	:	16806 INNOCENTE AVE
Second Line	:
City	:	PANAMA CITY BEACH
State	:	FL
Zip	:	32413-2318
Country	:	US
Telephone Number	:	850-234-1868
Fax Number	:	850-234-1468

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/05/2006
Last Update Date	:	07/08/2007

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