Healthcare Provider Details

I. General information

NPI: 1265482418
Provider Name (Legal Business Name): LINA NMN CLINE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 04/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 PARK EAST DR
ROSWELL GA
30075-3011
US

IV. Provider business mailing address

120 PARK EAST DR
ROSWELL GA
30075-3011
US

V. Phone/Fax

Practice location:
  • Phone: 678-523-4000
  • Fax:
Mailing address:
  • Phone: 678-523-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN139141
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: