Provider Demographics
NPI:1912946575
Name:HERN, DEDRA (CRNA)
Entity Type:Individual
Prefix:
First Name:DEDRA
Middle Name:
Last Name:HERN
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:PO BOX 850001 DEPT 0451
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32885-0451
Mailing Address - Country:US
Mailing Address - Phone:855-543-5604
Mailing Address - Fax:844-876-0873
Practice Address - Street 1:1601 38TH AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33713-1926
Practice Address - Country:US
Practice Address - Phone:317-614-9863
Practice Address - Fax:844-876-0873
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2702392367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL302936100Medicaid
FLK6463Medicare ID - Type UnspecifiedGROUP#
FLE5885CMedicare PIN