Provider Demographics
NPI:1962403964
Name:DALTON, NANCY (CRNA)
Entity type:Individual
Prefix:MS
First Name:NANCY
Middle Name:
Last Name:DALTON
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 1:8787 SOUTHSIDE BLVD
Mailing Address - Street 2:APT. 3619
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-3524
Mailing Address - Country:US
Mailing Address - Phone:904-538-0700
Mailing Address - Fax:904-296-4660
Practice Address - Street 1:4500 SAN PABLO RD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-1865
Practice Address - Country:US
Practice Address - Phone:904-296-4667
Practice Address - Fax:904-296-4660
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3279092367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY72972Medicare ID - Type Unspecified