Healthcare Provider Details

I. General information

NPI: 1801415872
Provider Name (Legal Business Name): HOLLY ELY CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2020
Last Update Date: 10/30/2025
Certification Date: 10/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 DIXIE ST
CARROLLTON GA
30117-3818
US

IV. Provider business mailing address

143 GWENDOLYN CT
CARROLLTON GA
30117-8103
US

V. Phone/Fax

Practice location:
  • Phone: 770-812-9666
  • Fax:
Mailing address:
  • Phone: 770-328-1089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberGAA-CRNA003198
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: