Provider Demographics
NPI:1336127752
Name:MANSOUR, PAULINE ANNE (CRNA ARNP)
Entity Type:Individual
Prefix:MS
First Name:PAULINE
Middle Name:ANNE
Last Name:MANSOUR
Suffix:
Gender:F
Credentials:CRNA ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13981 BENTLY CIRCLE
Mailing Address - Street 2:
Mailing Address - City:FT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-1988
Mailing Address - Country:US
Mailing Address - Phone:239-226-1491
Mailing Address - Fax:239-274-8766
Practice Address - Street 1:8380 RIVERWALK PARK BLVD
Practice Address - Street 2:#220
Practice Address - City:FT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919
Practice Address - Country:US
Practice Address - Phone:239-454-7544
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN30570052367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG2047Medicare ID - Type Unspecified