Provider Demographics
NPI:1023207982
Name:FISHER, MARILYN JEAN (CRNA)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:JEAN
Last Name:FISHER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MARILYN
Other - Middle Name:J
Other - Last Name:EDMISTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:25115 REDWOOD CT
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33955-6345
Mailing Address - Country:US
Mailing Address - Phone:412-609-7870
Mailing Address - Fax:
Practice Address - Street 1:636 DEL PRADO BLVD S
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-2695
Practice Address - Country:US
Practice Address - Phone:239-424-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-17
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11027614367500000X
VA0024169523367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1023207982Medicaid
VAQ37499AMedicare PIN