Healthcare Provider Details

I. General information

NPI: 1982112959
Provider Name (Legal Business Name): RYAN ELIZABETH GALLETTA CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2018
Last Update Date: 01/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 HEMLOCK ST
MACON GA
31201-2102
US

IV. Provider business mailing address

111 CHILDS RD
GRAY GA
31032-5680
US

V. Phone/Fax

Practice location:
  • Phone: 478-633-2129
  • Fax:
Mailing address:
  • Phone: 678-925-2773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number224026
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: