Provider Demographics
NPI:1073179735
Name:FAHRENHOLTZ, CHARLES GERARD (DNP,CRNA)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:GERARD
Last Name:FAHRENHOLTZ
Suffix:
Gender:M
Credentials:DNP,CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10043 GRAND CANAL DR UNIT 17301
Mailing Address - Street 2:
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786-5863
Mailing Address - Country:US
Mailing Address - Phone:504-818-4743
Mailing Address - Fax:
Practice Address - Street 1:700 W OAK ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4924
Practice Address - Country:US
Practice Address - Phone:407-846-2266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-17
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA9510615163W00000X
FLAPRN11003021367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse