Provider Demographics
NPI:1093786758
Name:BECKER, KATHY TINES (CRNA)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:TINES
Last Name:BECKER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KATHY
Other - Middle Name:ANITA
Other - Last Name:BECKER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:2005 KNIGHT LANE ATTN: MEDICAL STAFF SERVICES, BLDG H
Mailing Address - Street 2:NAVY MEDICINE SUPPORT COMMAND
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32212-0140
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 PINCKNEY BLVD
Practice Address - Street 2:NAVAL HOSPITAL BEAUFORT
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902-6148
Practice Address - Country:US
Practice Address - Phone:843-228-5200
Practice Address - Fax:843-228-5300
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-31
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1050175367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered