Provider Demographics
NPI:1710646005
Name:TAYLOR, JEANNINE TORRES (CRNA)
Entity Type:Individual
Prefix:
First Name:JEANNINE
Middle Name:TORRES
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:JEANNIE
Other - Middle Name:PATRICIA
Other - Last Name:TORRES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:61 9TH AVE UNIT C
Mailing Address - Street 2:
Mailing Address - City:SHALIMAR
Mailing Address - State:FL
Mailing Address - Zip Code:32579-1329
Mailing Address - Country:US
Mailing Address - Phone:770-262-4010
Mailing Address - Fax:
Practice Address - Street 1:1000 MAR WALT DR
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6708
Practice Address - Country:US
Practice Address - Phone:850-862-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-14
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11017301367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered