Provider Demographics
NPI:1417096116
Name:HOPE, JACQUELINE M (CRNA)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:M
Last Name:HOPE
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:PO BOX 868
Mailing Address - Street 2:807 W MAIN ST
Mailing Address - City:WILMINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:45177-0868
Mailing Address - Country:US
Mailing Address - Phone:937-382-1864
Mailing Address - Fax:937-382-8917
Practice Address - Street 1:807 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:OH
Practice Address - Zip Code:45177-0868
Practice Address - Country:US
Practice Address - Phone:937-382-1864
Practice Address - Fax:937-382-8917
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH051895367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000244724OtherANTHEM
OH2219870Medicaid
OHH08227943Medicare ID - Type Unspecified