Healthcare Provider Details

I. General information

NPI: 1639146830
Provider Name (Legal Business Name): DEANNA HOLLAND POWELL CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 04/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 TEBEAU ST
WAYCROSS GA
31501-6357
US

IV. Provider business mailing address

PO BOX 73709
NEWNAN GA
30271-3709
US

V. Phone/Fax

Practice location:
  • Phone: 912-338-6511
  • Fax: 912-338-6512
Mailing address:
  • Phone: 770-251-2060
  • Fax: 678-854-9235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN140357
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: