Healthcare Provider Details

I. General information

NPI: 1962776849
Provider Name (Legal Business Name): KATIE T COLE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATIE B TARBUSH

II. Dates (important events)

Enumeration Date: 02/24/2012
Last Update Date: 06/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1455 MONTREAL RD
TUCKER GA
30084
US

IV. Provider business mailing address

101 W PONCE DE LEON AVE
DECATUR GA
30030-2542
US

V. Phone/Fax

Practice location:
  • Phone: 404-251-3000
  • Fax:
Mailing address:
  • Phone: 404-778-2528
  • Fax: 404-778-3001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN183626
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: