Healthcare Provider Details

I. General information

NPI: 1023489937
Provider Name (Legal Business Name): JACK POWELL CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2015
Last Update Date: 09/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

743 SPRING ST NE
GAINESVILLE GA
30501-3715
US

IV. Provider business mailing address

1557 JANMAR RD
SNELLVILLE GA
30078-5686
US

V. Phone/Fax

Practice location:
  • Phone: 770-532-7179
  • Fax: 770-534-1312
Mailing address:
  • Phone: 678-344-8900
  • Fax: 678-666-5201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN202066
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: