Healthcare Provider Details

I. General information

NPI: 1437502085
Provider Name (Legal Business Name): SHELLY LAUREN HERETH CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHELLY LAUREN STEED CRNA

II. Dates (important events)

Enumeration Date: 07/19/2016
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 MEMORIAL DR
DALTON GA
30720-2529
US

IV. Provider business mailing address

385 DAVIS RIDGE RD
RINGGOLD GA
30736-5900
US

V. Phone/Fax

Practice location:
  • Phone: 706-272-6000
  • Fax: 423-602-8401
Mailing address:
  • Phone: 423-645-0902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN200088
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPN21838
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN213029
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: