Provider Demographics
NPI:1881990356
Name:BRABHAM, ILUSION (CRNA)
Entity type:Individual
Prefix:MRS
First Name:ILUSION
Middle Name:
Last Name:BRABHAM
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:829 CHANTERELLE WAY
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-8001
Mailing Address - Country:US
Mailing Address - Phone:904-392-6694
Mailing Address - Fax:
Practice Address - Street 1:2165 HERSCHEL ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-3819
Practice Address - Country:US
Practice Address - Phone:904-381-4030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-01
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN 9261912367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered