Provider Demographics
NPI:1679635924
Name:DEDRA HERN CRNA LLC
Entity Type:Organization
Organization Name:DEDRA HERN CRNA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:HERN
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:813-215-4960
Mailing Address - Street 1:PO BOX 850001 DEPT 0451
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32885-0451
Mailing Address - Country:US
Mailing Address - Phone:855-543-5604
Mailing Address - Fax:855-679-5160
Practice Address - Street 1:1601 38TH AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33713-1926
Practice Address - Country:US
Practice Address - Phone:317-614-9863
Practice Address - Fax:844-876-0873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2702392367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDC1392OtherRAILROAD MEDICARE
FLG9055OtherFL BLUE CROSS
FL306290200Medicaid
FL306290200Medicaid