Healthcare Provider Details

I. General information

NPI: 1588691695
Provider Name (Legal Business Name): LYNN M GRANDGENETT CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 10/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2808 S 143RD PLZ
OMAHA NE
68144-5611
US

IV. Provider business mailing address

804 SCOTT NIXON MEMORIAL DR
AUGUSTA GA
30907-2464
US

V. Phone/Fax

Practice location:
  • Phone: 402-637-0600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number56598
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: