Provider Demographics
NPI:1699291021
Name:CABAN-HERNANDEZ, KIOMARY (CRNA)
Entity type:Individual
Prefix:
First Name:KIOMARY
Middle Name:
Last Name:CABAN-HERNANDEZ
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 1:1911 MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33763-4522
Mailing Address - Country:US
Mailing Address - Phone:939-642-5681
Mailing Address - Fax:
Practice Address - Street 1:11375 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-5409
Practice Address - Country:US
Practice Address - Phone:352-596-6632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-17
Last Update Date:2018-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR38433367500000X
PA697518367500000X
FL9469923367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered