Healthcare Provider Details

I. General information

NPI: 1700105103
Provider Name (Legal Business Name): HOLLY D. PAYNE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2010
Last Update Date: 12/20/2018
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 C/O CLINIC MANAGEMENT
CALHOUN GA
30703
US

V. Phone/Fax

Practice location:
  • Phone: 706-879-4776
  • Fax: 706-879-5841
Mailing address:
  • Phone:
  • Fax: 478-745-4849

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number8059565-4406
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN144655
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: