Healthcare Provider Details

I. General information

NPI: 1043417702
Provider Name (Legal Business Name): CHERYL L WORTHEN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 11/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 JOHNSON FERRY ROAD
ATLANTA GA
30342
US

IV. Provider business mailing address

3155 N POINT PKWY ATTN CREDENTIALING DEPT, BUILDING F, SUITE 100
ALPHARETTA GA
30005
US

V. Phone/Fax

Practice location:
  • Phone: 770-645-9181
  • Fax: 770-645-8455
Mailing address:
  • Phone: 770-645-9181
  • Fax: 770-645-8455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN160124
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: