Healthcare Provider Details

I. General information

NPI: 1649552977
Provider Name (Legal Business Name): KATHLEEN HURLBUT GANGL CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2011
Last Update Date: 02/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5126 HOSPITAL DR NE
COVINGTON GA
30014-2566
US

IV. Provider business mailing address

405 ARROWHEAD BLVD STE C
JONESBORO GA
30236-1254
US

V. Phone/Fax

Practice location:
  • Phone: 770-478-9877
  • Fax:
Mailing address:
  • Phone: 770-478-9877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN176791
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: