Provider Demographics
NPI:1275655987
Name:JUSTYN, MARY A (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:A
Last Name:JUSTYN
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 1:1888 GARDENIA ST
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-1908
Mailing Address - Country:US
Mailing Address - Phone:904-261-7115
Mailing Address - Fax:
Practice Address - Street 1:1900 TEBEAU ST
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-6357
Practice Address - Country:US
Practice Address - Phone:912-338-6511
Practice Address - Fax:912-338-6512
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2012-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9183190367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000941817DMedicaid
GAP00853009Medicare PIN
GA202I430266Medicare PIN
FLE6845ZMedicare PIN