Healthcare Provider Details

I. General information

NPI: 1932157484
Provider Name (Legal Business Name): KENDALL MARK BROOME CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

Provider Other Name: MARK BROOME CRNA

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 10/03/2021
Certification Date: 10/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5671 PEACHTREE-DUNWOODY RD STE 680
ATLANTA GA
30342-5014
US

IV. Provider business mailing address

PO BOX 740209 DEPT 1041
ATLANTA GA
30374-0209
US

V. Phone/Fax

Practice location:
  • Phone: 404-705-6985
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN 135213
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: