Basic Information
| Provider Information | |||||||||
| NPI: | 1780652669 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ABDALLAH | ||||||||
| FirstName: | VIVIAN | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3601 W COMMERCIAL BLVD | ||||||||
| Address2: | STE 5 C/O ANESCO NORTH BROWARD LLC | ||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544855666 | ||||||||
| FaxNumber: | 9544841651 | ||||||||
| Practice Location | |||||||||
| Address1: | C/O NORTH BROWARD MEDICAL CENTER | ||||||||
| Address2: | 201 EAST SAMPLE ROAD | ||||||||
| City: | DEERFIELD BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547866755 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2006 | ||||||||
| LastUpdateDate: | 04/21/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | ARNP3079752 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 305935900 | 05 | FL | MEDICAID |