Provider Demographics
NPI:1285238766
Name:FLORES, GINA (CRNA)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:FLORES
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:
Other - Last Name:DIAZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2906 LEON CV
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-0085
Mailing Address - Country:US
Mailing Address - Phone:915-472-2769
Mailing Address - Fax:
Practice Address - Street 1:1200 RALSTON AVE
Practice Address - Street 2:
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512-1396
Practice Address - Country:US
Practice Address - Phone:419-783-6955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-25
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28262987A163W00000X
IN28262987C163W00000X
MI4704398418367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse