Healthcare Provider Details

I. General information

NPI: 1245859933
Provider Name (Legal Business Name): MITCHELL CROSLEY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MITCHELL CROSLEY CRNA

II. Dates (important events)

Enumeration Date: 04/13/2020
Last Update Date: 11/14/2022
Certification Date: 07/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 POPLAR RD
NEWNAN GA
30265-1618
US

IV. Provider business mailing address

1509 PARKER ST
FRANKLINTON LA
70438-1233
US

V. Phone/Fax

Practice location:
  • Phone: 770-400-1000
  • Fax:
Mailing address:
  • Phone: 985-515-5013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN134638
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2021024027
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberGAA-CRNA000409
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: