Healthcare Provider Details

I. General information

NPI: 1164982062
Provider Name (Legal Business Name): EMILY KATHLYN PETERS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2019
Last Update Date: 09/23/2021
Certification Date: 09/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 JOHNSON FERRY RD
ATLANTA GA
30342-1606
US

IV. Provider business mailing address

1840 TOBEY RD
ATLANTA GA
30341-4832
US

V. Phone/Fax

Practice location:
  • Phone: 770-645-5117
  • Fax:
Mailing address:
  • Phone: 678-371-0733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN250049
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN250049
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: