Provider Demographics
NPI:1639139694
Name:CASANTA, JENNIFER GRACE (CRNA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:GRACE
Last Name:CASANTA
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:GRACE
Other - Last Name:WATERWORTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:1120 3RD AVE S
Mailing Address - Street 2:
Mailing Address - City:TIERRA VERDE
Mailing Address - State:FL
Mailing Address - Zip Code:33715-2229
Mailing Address - Country:US
Mailing Address - Phone:813-765-7799
Mailing Address - Fax:
Practice Address - Street 1:1200 7TH AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33705-1300
Practice Address - Country:US
Practice Address - Phone:727-825-2486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3062322367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL307539700Medicaid
FLG4273OtherBCBS
FLAA486YMedicare PIN
FLG4273OtherBCBS