Healthcare Provider Details

I. General information

NPI: 1841672409
Provider Name (Legal Business Name): ELLEN RACHEL GENTRY CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELLEN RACHEL SANDIDGE R.N.

II. Dates (important events)

Enumeration Date: 06/19/2015
Last Update Date: 12/14/2023
Certification Date: 12/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 HILLDALE DR
CHATTANOOGA TN
37411-1806
US

IV. Provider business mailing address

111 HILLDALE DR
CHATTANOOGA TN
37411-1806
US

V. Phone/Fax

Practice location:
  • Phone: 423-802-1545
  • Fax:
Mailing address:
  • Phone: 423-843-9252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License NumberRN0000149664
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberGAA-CRNA000992
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number20658
License Number StateTN
# 4
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN0000149664
License Number StateTN
# 5
Primary TaxonomyN
Taxonomy Code163WN0800X
TaxonomyNeuroscience Registered Nurse
License NumberRN0000149664
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: