Healthcare Provider Details

I. General information

NPI: 1013465038
Provider Name (Legal Business Name): LAURA COTHERN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2016
Last Update Date: 10/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1035 RED BUD RD NE
CALHOUN GA
30701-6010
US

IV. Provider business mailing address

PO BOX 12938
CALHOUN GA
30703-7013
US

V. Phone/Fax

Practice location:
  • Phone: 706-624-5079
  • Fax: 706-879-5841
Mailing address:
  • Phone: 706-602-7800
  • Fax: 706-879-5843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number111900
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: