Basic Information
| Provider Information | |||||||||
| NPI: | 1780939561 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CACCIAPALLE | ||||||||
| FirstName: | KATIE | ||||||||
| MiddleName: | R | ||||||||
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| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RUFFIN | ||||||||
| OtherFirstName: | KATIE | ||||||||
| OtherMiddleName: | M | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 551420 | ||||||||
| Address2: | |||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333551420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002433839 | ||||||||
| FaxNumber: | 8558514405 | ||||||||
| Practice Location | |||||||||
| Address1: | 777 HEMLOCK ST | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312012102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4786332147 | ||||||||
| FaxNumber: | 4787429670 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2012 | ||||||||
| LastUpdateDate: | 10/17/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | ARNP9301121 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 4704296775 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367H00000X | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
ID Information
| ID | Type | State | Issuer | Description | 4704296775 | 01 | MI | MI LICENSE | OTHER |