Healthcare Provider Details

I. General information

NPI: 1194790907
Provider Name (Legal Business Name): VERONICA CHAMBLISS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 10/12/2025
Certification Date: 10/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1412 MILSTEAD AVE NE
CONYERS GA
30012-3877
US

IV. Provider business mailing address

1388B WELLBROOK CIR NE
CONYERS GA
30012-3872
US

V. Phone/Fax

Practice location:
  • Phone: 770-388-7745
  • Fax: 770-922-0526
Mailing address:
  • Phone: 770-388-7745
  • Fax: 770-922-0526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number061139
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: