Healthcare Provider Details

I. General information

NPI: 1164405304
Provider Name (Legal Business Name): TERESA DIANNE HUTSON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TERESA DIANNE HESTER CRNA

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 01/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

865 S 1ST ST
JESUP GA
31545-0210
US

IV. Provider business mailing address

PO BOX 2585
COLUMBUS GA
31902-2585
US

V. Phone/Fax

Practice location:
  • Phone: 912-427-6811
  • Fax: 706-660-9390
Mailing address:
  • Phone: 706-660-8505
  • Fax: 706-660-9390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN082039
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: