Healthcare Provider Details

I. General information

NPI: 1891934758
Provider Name (Legal Business Name): DANIEL L DELL CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2009
Last Update Date: 01/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3131 S MAIN ST
MOULTRIE GA
31768-6925
US

IV. Provider business mailing address

142 TANGLEWOOD DR
MOULTRIE GA
31768-7983
US

V. Phone/Fax

Practice location:
  • Phone: 229-891-9131
  • Fax: 229-891-9079
Mailing address:
  • Phone: 229-456-0450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN147088
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: