Basic Information
| Provider Information | |||||||||
| NPI: | 1124095104 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRAMER | ||||||||
| FirstName: | JACKLYN | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3601 W COMMERCIAL BLVD | ||||||||
| Address2: | SUITE 5 | ||||||||
| City: | FT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333093300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544855666 | ||||||||
| FaxNumber: | 9544841651 | ||||||||
| Practice Location | |||||||||
| Address1: | 3601 W COMMERCIAL BLVD | ||||||||
| Address2: | SUITE 5 | ||||||||
| City: | FT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333093300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544855666 | ||||||||
| FaxNumber: | 9544841651 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2006 | ||||||||
| LastUpdateDate: | 03/07/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | ARNP2570402 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 034952600 | 05 | FL | MEDICAID | ARNP2570402 | 01 | FL | FL LIC | OTHER | G1724 | 01 | FL | BCBS | OTHER |