Healthcare Provider Details

I. General information

NPI: 1740011402
Provider Name (Legal Business Name): AMY ELLISON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2024
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 VINE ST
WINSTON SALEM NC
27101-4125
US

IV. Provider business mailing address

203 29TH AVE NE UNIT 51
HICKORY NC
28601-1373
US

V. Phone/Fax

Practice location:
  • Phone: 336-716-1411
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number159495
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: