Healthcare Provider Details

I. General information

NPI: 1730375288
Provider Name (Legal Business Name): WALTER KENNEDY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

401 E VAUGHN AVE
RUSTON LA
71270-5950
US

IV. Provider business mailing address

PO BOX 25108
CHATTANOOGA TN
37422-5108
US

V. Phone/Fax

Practice location:
  • Phone: 318-254-2100
  • Fax: 318-254-2728
Mailing address:
  • Phone: 318-254-2100
  • Fax: 318-254-2728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN039167
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: