Provider Demographics
NPI:1649737867
Name:CRISAFI, DOMINIQUE (CRNA)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:CRISAFI
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 1:4523 CRESTBROOK DR
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32404-5208
Mailing Address - Country:US
Mailing Address - Phone:850-803-1556
Mailing Address - Fax:
Practice Address - Street 1:449 W 23RD ST
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4507
Practice Address - Country:US
Practice Address - Phone:850-803-1556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-24
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11010521367500000X
NY703879163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine