Provider Demographics
NPI:1336100270
Name:DEHAVEN, JANITH S (CRNA)
Entity Type:Individual
Prefix:
First Name:JANITH
Middle Name:S
Last Name:DEHAVEN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:JANITH
Other - Middle Name:S
Other - Last Name:PRATT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 6907
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36302
Mailing Address - Country:US
Mailing Address - Phone:334-793-5000
Mailing Address - Fax:334-615-8419
Practice Address - Street 1:4370 W MAIN STREET
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305
Practice Address - Country:US
Practice Address - Phone:334-793-5000
Practice Address - Fax:334-615-8419
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1026900367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03737502Medicaid
AL51515737OtherBLUE CROSS BLUE SHIELD
P00055593OtherRR MEDICARE
LA1772445Medicaid
LA1772445Medicaid