Provider Demographics
NPI:1316949126
Name:HARRELL, MARDIS H (CRNA)
Entity type:Individual
Prefix:
First Name:MARDIS
Middle Name:H
Last Name:HARRELL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 CLIFFORD DR
Mailing Address - Street 2:
Mailing Address - City:SHALIMAR
Mailing Address - State:FL
Mailing Address - Zip Code:32579-1251
Mailing Address - Country:US
Mailing Address - Phone:850-651-5313
Mailing Address - Fax:
Practice Address - Street 1:928 MAR WALT DR
Practice Address - Street 2:SUITE 201
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6706
Practice Address - Country:US
Practice Address - Phone:850-862-4377
Practice Address - Fax:850-862-6015
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 2135062163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse