Provider Demographics
NPI:1770885717
Name:RUSCH, JACQUELINE R (CRNA)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:R
Last Name:RUSCH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:R
Other - Last Name:BERTMEYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2400
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32902-2400
Mailing Address - Country:US
Mailing Address - Phone:321-837-3820
Mailing Address - Fax:603-893-8886
Practice Address - Street 1:1350 HICKORY ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3224
Practice Address - Country:US
Practice Address - Phone:321-837-3820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-24
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.11919-NA367500000X
FLARNP9361702367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered