Provider Demographics
NPI:1649700907
Name:LIST, CASSANDRA NICOLE
Entity type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:NICOLE
Last Name:LIST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10968 NW 3RD ST
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33071-8116
Mailing Address - Country:US
Mailing Address - Phone:954-376-1709
Mailing Address - Fax:
Practice Address - Street 1:2815 S SEACREST BLVD
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33435-7969
Practice Address - Country:US
Practice Address - Phone:561-292-4663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-19
Last Update Date:2017-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9463521367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered