Provider Demographics
NPI:1417946435
Name:COLLUCCI, SANDRA KAY (CRNA)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:KAY
Last Name:COLLUCCI
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:KAY
Other - Last Name:SCHROEDER COLLUCCI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:4048 EVANS AVE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:FT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9322
Mailing Address - Country:US
Mailing Address - Phone:239-332-5344
Mailing Address - Fax:239-332-7246
Practice Address - Street 1:4048 EVANS AVE
Practice Address - Street 2:SUITE 303
Practice Address - City:FT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-9322
Practice Address - Country:US
Practice Address - Phone:239-332-5344
Practice Address - Fax:239-332-7246
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2009-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1128462367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL430042583OtherMCRR
FL304108500Medicaid
FLG1043WOtherMCR
FLG1043OtherBSFL