Healthcare Provider Details

I. General information

NPI: 1356708945
Provider Name (Legal Business Name): TIMOTHY KEITH KANEY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2016
Last Update Date: 02/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 CLARK RD
BRISTOL TN
37620-7400
US

IV. Provider business mailing address

1144 N ROAD ST
ELIZABETH CITY NC
27909-3473
US

V. Phone/Fax

Practice location:
  • Phone: 423-967-8764
  • Fax:
Mailing address:
  • Phone: 252-384-2610
  • Fax: 252-338-2505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number183498
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: