Healthcare Provider Details

I. General information

NPI: 1346350980
Provider Name (Legal Business Name): MISTY W TIBBITT CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 12/05/2023
Certification Date: 12/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5106 GA HIGHWAY 41 S
BUENA VISTA GA
31803-8801
US

IV. Provider business mailing address

PO BOX 4380
ALPHARETTA GA
30023-4380
US

V. Phone/Fax

Practice location:
  • Phone: 706-741-1361
  • Fax:
Mailing address:
  • Phone: 706-741-1361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number154668
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: