Healthcare Provider Details

I. General information

NPI: 1295703742
Provider Name (Legal Business Name): HYACINTH D. SPENCE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 12/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1133 EAGLES LANDING PKWY
STOCKBRIDGE GA
30281-5085
US

IV. Provider business mailing address

PO BOX 102966
ATLANTA GA
30368-2966
US

V. Phone/Fax

Practice location:
  • Phone: 770-389-2200
  • Fax: 770-237-1124
Mailing address:
  • Phone: 770-237-1561
  • Fax: 770-237-1124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN147966
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: