Provider Demographics
NPI:1942759428
Name:RACKLEY, KEITH (CRNA)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:RACKLEY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8390 CHAMPIONS GATE BLVD STE 215
Mailing Address - Street 2:
Mailing Address - City:CHAMPIONS GATE
Mailing Address - State:FL
Mailing Address - Zip Code:33896-8310
Mailing Address - Country:US
Mailing Address - Phone:407-390-1677
Mailing Address - Fax:407-390-1765
Practice Address - Street 1:8390 CHAMPIONS GATE BLVD STE 215
Practice Address - Street 2:
Practice Address - City:CHAMPIONS GATE
Practice Address - State:FL
Practice Address - Zip Code:33896-8310
Practice Address - Country:US
Practice Address - Phone:407-390-1677
Practice Address - Fax:407-390-1765
Is Sole Proprietor?:No
Enumeration Date:2016-09-26
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9360027367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered