Provider Demographics
NPI:1003528514
Name:PETERSON, MANDEE (CRNA)
Entity Type:Individual
Prefix:
First Name:MANDEE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 CENTRAL AVE UNIT 575
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33713-8992
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 PINELLAS ST
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-3804
Practice Address - Country:US
Practice Address - Phone:727-462-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-15
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL147010367500000X
FL11023841367500000X
FL9454708163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty