Healthcare Provider Details

I. General information

NPI: 1437404076
Provider Name (Legal Business Name): ASHLEY J KEETON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2012
Last Update Date: 12/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

380 HOSPITAL DRIVE SUITE 410
MACON GA
31217
US

IV. Provider business mailing address

PO BOX 2564
MACON GA
31203-2564
US

V. Phone/Fax

Practice location:
  • Phone: 478-746-5644
  • Fax: 478-745-4849
Mailing address:
  • Phone: 478-746-5644
  • Fax: 478-745-4849

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberTLRN039376
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1911178
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: