Basic Information
| Provider Information | |||||||||
| NPI: | 1962479691 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALE | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | LYNNE | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 918025 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328918025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435537070 | ||||||||
| FaxNumber: | 8435532223 | ||||||||
| Practice Location | |||||||||
| Address1: | 9326 MEDICAL PLAZA DR | ||||||||
| Address2: | STE B | ||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294069138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435537070 | ||||||||
| FaxNumber: | 8435532223 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2006 | ||||||||
| LastUpdateDate: | 02/24/2010 | ||||||||
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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 | APN 2549 | SC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | ARNP9288188 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | AN1382 | 05 | SC | MEDICAID |