Provider Demographics
NPI:1649694654
Name:GARRETT, MARIE ALTAGRACE (CRNA)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:ALTAGRACE
Last Name:GARRETT
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:ALTAGRACE
Other - Last Name:GARRETT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:4700 LAS VEGAS BLVD N
Mailing Address - Street 2:
Mailing Address - City:NELLIS AFB
Mailing Address - State:NV
Mailing Address - Zip Code:89191-6600
Mailing Address - Country:US
Mailing Address - Phone:702-653-3550
Mailing Address - Fax:
Practice Address - Street 1:4700 LAS VEGAS BLVD N
Practice Address - Street 2:
Practice Address - City:NELLIS AFB
Practice Address - State:NV
Practice Address - Zip Code:89191
Practice Address - Country:US
Practice Address - Phone:702-653-3550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-11
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9270307367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPENDINGOtherBCBS
FLPENDINGMedicaid
FLPENDINGMedicaid