Provider Demographics
NPI:1104041862
Name:KING, RICKEY (CRNA)
Entity Type:Individual
Prefix:
First Name:RICKEY
Middle Name:
Last Name:KING
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7152 COCA SABAL LN
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-4263
Mailing Address - Country:US
Mailing Address - Phone:239-985-0215
Mailing Address - Fax:305-675-3378
Practice Address - Street 1:777 HEMLOCK ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2102
Practice Address - Country:US
Practice Address - Phone:478-633-6706
Practice Address - Fax:478-633-5384
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9448508367500000X
GARN138591367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered