Healthcare Provider Details

I. General information

NPI: 1396126843
Provider Name (Legal Business Name): JESSICA SEWELL CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2015
Last Update Date: 06/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2655 NORTHWINDS PKWY
ALPHARETTA GA
30009-2280
US

IV. Provider business mailing address

2105 E SOUTH BLVD
MONTGOMERY AL
36116-2409
US

V. Phone/Fax

Practice location:
  • Phone: 770-643-5619
  • Fax:
Mailing address:
  • Phone: 770-643-5619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1-117861
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: