Healthcare Provider Details

I. General information

NPI: 1336106616
Provider Name (Legal Business Name): REATHA W. BALLARD CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 08/26/2020
Certification Date: 08/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 MILES ST
DAMARISCOTTA ME
04543-4047
US

IV. Provider business mailing address

1414 GOLDEN SPRINGSROAD #305
ANNISTON AL
36207
US

V. Phone/Fax

Practice location:
  • Phone: 207-563-4904
  • Fax:
Mailing address:
  • Phone: 256-239-0569
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1-025847
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: