Healthcare Provider Details

I. General information

NPI: 1427043983
Provider Name (Legal Business Name): JENNIFER TRICIA WILLIS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNIFER TRICIA BROLO CRNA

II. Dates (important events)

Enumeration Date: 09/12/2005
Last Update Date: 12/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2608 CREST VALLEY DRIVE
CONYERS GA
30094
US

IV. Provider business mailing address

2608 CREST VALLEY DRIVE
CONYERS GA
30094
US

V. Phone/Fax

Practice location:
  • Phone: 404-428-2237
  • Fax: 404-428-2237
Mailing address:
  • Phone: 770-648-8237
  • Fax: 770-648-8237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number180459
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: