Provider Demographics
NPI:1861448805
Name:MIKLIC, GAIL (CRNA)
Entity Type:Individual
Prefix:
First Name:GAIL
Middle Name:
Last Name:MIKLIC
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 1:13981 EAGLE RIDGE LAKES DR
Mailing Address - Street 2:#201
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-8801
Mailing Address - Country:US
Mailing Address - Phone:239-768-9195
Mailing Address - Fax:
Practice Address - Street 1:3949 EVANS AVE STE 102
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-9341
Practice Address - Country:US
Practice Address - Phone:239-939-2622
Practice Address - Fax:239-939-0151
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1253002367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL303160800Medicaid