Provider Demographics
NPI:1417134594
Name:WAHLSTROM, DEBRA (CRNA)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:WAHLSTROM
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 1:4519 GEORGE RD
Mailing Address - Street 2:STE 100
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-7329
Mailing Address - Country:US
Mailing Address - Phone:813-496-1075
Mailing Address - Fax:
Practice Address - Street 1:4519 GEORGE RD
Practice Address - Street 2:STE 100
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33634-7329
Practice Address - Country:US
Practice Address - Phone:813-496-1075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-30
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9178022367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered