Healthcare Provider Details

I. General information

NPI: 1376596106
Provider Name (Legal Business Name): JEFFREY L CUNNINGHAM CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 HIGHWAY 770
CORBIN KY
40701-4732
US

IV. Provider business mailing address

PO BOX 33087
KNOXVILLE TN
37930-3087
US

V. Phone/Fax

Practice location:
  • Phone: 606-526-7874
  • Fax:
Mailing address:
  • Phone: 865-691-2993
  • Fax: 865-691-2997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN1100047/ARNP3927A
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: