Basic Information
| Provider Information | |||||||||
| NPI: | 1962969733 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EDDY | ||||||||
| FirstName: | YESSENIA | ||||||||
| MiddleName: | ESPEJO | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ESPEJO | ||||||||
| OtherFirstName: | YESSENIA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CRNA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1525 W CYPRESS CREEK RD | ||||||||
| Address2: | |||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333091831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592681030 | ||||||||
| FaxNumber: | 8592694120 | ||||||||
| Practice Location | |||||||||
| Address1: | 1525 W CYPRESS CREEK RD | ||||||||
| Address2: | |||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333091831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592681030 | ||||||||
| FaxNumber: | 8592694120 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2019 | ||||||||
| LastUpdateDate: | 02/17/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | APRN11010701 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 3013190 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 163W00000X | 11010701 | FL | N | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | APRN11010701 | 05 | FL | MEDICAID |