Provider Demographics
NPI:1447723457
Name:GONTIS, JOLYN MARIE (CRNA)
Entity type:Individual
Prefix:
First Name:JOLYN
Middle Name:MARIE
Last Name:GONTIS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:JOLYN
Other - Middle Name:MARIE
Other - Last Name:PELESKY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:7700 W SUNRISE BLVD
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33322-4113
Mailing Address - Country:US
Mailing Address - Phone:954-939-5554
Mailing Address - Fax:
Practice Address - Street 1:1000 MAR WALT DR
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6708
Practice Address - Country:US
Practice Address - Phone:850-862-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-03
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COC-APN.0004013-C-CRNA367500000X
VA0024186641367500000X
FLAPRN11000725367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered