Provider Demographics
NPI:1083216782
Name:MINNICK, CHRISTINE HERRERA (CRNA)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:HERRERA
Last Name:MINNICK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:CHRISTINE
Other - Middle Name:ANNE
Other - Last Name:HERRERA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1234 WAVERLY RD
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32312-2866
Mailing Address - Country:US
Mailing Address - Phone:251-377-6865
Mailing Address - Fax:
Practice Address - Street 1:2601 BLAIRSTONE RD STE GC3
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301-5939
Practice Address - Country:US
Practice Address - Phone:251-377-6865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-09
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FL11010913367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program