Healthcare Provider Details

I. General information

NPI: 1255757787
Provider Name (Legal Business Name): CALLIE MATNEY CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2014
Last Update Date: 06/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL PARK BLVD
BRISTOL TN
37620-7430
US

IV. Provider business mailing address

105 W STONE DR SUITE 6A
KINGSPORT TN
37660-3365
US

V. Phone/Fax

Practice location:
  • Phone: 423-844-2686
  • Fax: 423-844-2688
Mailing address:
  • Phone: 423-408-7220
  • Fax: 423-408-7405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number100104
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: