Healthcare Provider Details

I. General information

NPI: 1225596661
Provider Name (Legal Business Name): JESSICA NICHOLE EWALT CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2019
Last Update Date: 03/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 WATERS AVE
SAVANNAH GA
31404-6220
US

IV. Provider business mailing address

3 WOODCOCK RD UNIT 4301
SAVANNAH GA
31404-1096
US

V. Phone/Fax

Practice location:
  • Phone: 912-350-8000
  • Fax:
Mailing address:
  • Phone: 708-921-7340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN282208
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: