Healthcare Provider Details

I. General information

NPI: 1205166519
Provider Name (Legal Business Name): KIMBERLY LYNN COWAN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2010
Last Update Date: 03/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2855 OLD HIGHWAY 5
BLUE RIDGE GA
30513-6248
US

IV. Provider business mailing address

311 WINTER DR
MORGANTON GA
30560-8210
US

V. Phone/Fax

Practice location:
  • Phone: 706-632-3711
  • Fax:
Mailing address:
  • Phone: 706-374-0408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number9189783
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number237082
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: