Provider Demographics
NPI:1265187819
Name:MULDER, JACQUELINE (CRNA)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:MULDER
Suffix:
Gender:
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2119 CATALONIA WAY S
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33712-4159
Mailing Address - Country:US
Mailing Address - Phone:616-299-5485
Mailing Address - Fax:
Practice Address - Street 1:501 6TH AVE S
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4634
Practice Address - Country:US
Practice Address - Phone:727-898-7451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-12
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9448689367500000X
MI4704311252367500000X
FLAPRN11019591367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL114607100Medicaid