Provider Demographics
NPI:1790763357
Name:WEISFELD, MARY LYON (CRNA)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:LYON
Last Name:WEISFELD
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 1:5354 TIMBERLANE RD
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33898-8959
Mailing Address - Country:US
Mailing Address - Phone:276-628-5017
Mailing Address - Fax:
Practice Address - Street 1:5354 TIMBERLANE RD
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33898-8959
Practice Address - Country:US
Practice Address - Phone:276-973-5683
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-04
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN38592367500000X
VA027870367500000X
VA0001056478367500000X
FLARNP9389844367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
4061629OtherBLUE CROSS OF TENNESSEE
3623574Medicare PIN