Provider Demographics
NPI:1518325513
Name:LAKE TIME CRNA
Entity Type:Organization
Organization Name:LAKE TIME CRNA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFF MGR
Authorized Official - Prefix:
Authorized Official - First Name:CECE
Authorized Official - Middle Name:
Authorized Official - Last Name:PANNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-294-7444
Mailing Address - Street 1:PO BOX 2626
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76113-2626
Mailing Address - Country:US
Mailing Address - Phone:817-294-7444
Mailing Address - Fax:817-294-7172
Practice Address - Street 1:9301 N CENTRAL EXPY
Practice Address - Street 2:SUITE 1000W
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-0806
Practice Address - Country:US
Practice Address - Phone:214-265-2810
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-04
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX661498367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty