Provider Demographics
NPI:1407833379
Name:ROBERTSON, MARY NYLENE (CRNA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:NYLENE
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:NYLENE
Other - Last Name:EDMONDSON/SKINNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 452198
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33345-2198
Mailing Address - Country:US
Mailing Address - Phone:954-838-2371
Mailing Address - Fax:
Practice Address - Street 1:2173A CENTERVILLE PL
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4356
Practice Address - Country:US
Practice Address - Phone:850-385-0144
Practice Address - Fax:850-385-0146
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2139282367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG1828ZMedicare ID - Type Unspecified