Provider Demographics
NPI:1992765614
Name:MCCLURE, THERESA ANN (CRNA)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:ANN
Last Name:MCCLURE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:ANN
Other - Last Name:BERTUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 57100
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32241-7100
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3625 UNIVERSITY BLVD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4207
Practice Address - Country:US
Practice Address - Phone:904-421-2119
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1485122367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG2539Medicare ID - Type Unspecified