Provider Demographics
NPI:1306810940
Name:FLANNERY, JILL SUZANNE (CRNA)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:SUZANNE
Last Name:FLANNERY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:SUZANNE
Other - Last Name:PETONOVICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:23 RIO VISTA DR
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34996-6423
Mailing Address - Country:US
Mailing Address - Phone:772-781-5804
Mailing Address - Fax:
Practice Address - Street 1:23 RIO VISTA DR
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34996-6423
Practice Address - Country:US
Practice Address - Phone:772-781-5804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9205024367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG3491OtherBCBS OF FLORIDA
FL306073000Medicaid
FLG3491XMedicare PIN
FLG3491ZMedicare PIN