Basic Information
Provider Information | |||||||||
NPI: | 1093760043 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WREN | ||||||||
FirstName: | KATHLEEN | ||||||||
MiddleName: | R. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2479 PONKAN SUMMIT DR | ||||||||
Address2: |   | ||||||||
City: | APOPKA | ||||||||
State: | FL | ||||||||
PostalCode: | 327126415 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3367161415 | ||||||||
FaxNumber: | 3367161412 | ||||||||
Practice Location | |||||||||
Address1: | MEDICAL CENTER DRIVE | ||||||||
Address2: | NURSE ANESTHESIA PROGRAM | ||||||||
City: | WINSTON-SALEM | ||||||||
State: | NC | ||||||||
PostalCode: | 271570001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4073039331 | ||||||||
FaxNumber: | 4073039578 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/24/2006 | ||||||||
LastUpdateDate: | 08/13/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | AP03921 | LA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   | 367500000X | ARNP 9263820 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
No ID Information.