Healthcare Provider Details

I. General information

NPI: 1942336581
Provider Name (Legal Business Name): CONELIA STACIE AVERY CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 02/11/2022
Certification Date: 02/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2326 HIGHWAY 34 E STE 100
NEWNAN GA
30265-1328
US

IV. Provider business mailing address

1115 MONTCLAIR DR
PEACHTREE CITY GA
30269-1879
US

V. Phone/Fax

Practice location:
  • Phone: 770-683-9840
  • Fax:
Mailing address:
  • Phone: 678-371-6105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN144288 CRNA
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: