Healthcare Provider Details

I. General information

NPI: 1972577724
Provider Name (Legal Business Name): CHANDRA GIRDHARI CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2006
Last Update Date: 10/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1412 MILSTEAD AVE NE
CONYERS GA
30012-3877
US

IV. Provider business mailing address

850 ORMEWOOD AVE SE
ATLANTA GA
30316-2435
US

V. Phone/Fax

Practice location:
  • Phone: 770-918-3000
  • Fax:
Mailing address:
  • Phone: 305-814-3253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number078583
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: