Healthcare Provider Details

I. General information

NPI: 1013088194
Provider Name (Legal Business Name): GLEN ROLAND HORNE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 DESALES AVE
CHATTANOOGA TN
37404-1161
US

IV. Provider business mailing address

5 CALHOUN AVE UNIT 606
DESTIN FL
32541-5509
US

V. Phone/Fax

Practice location:
  • Phone: 423-206-5040
  • Fax:
Mailing address:
  • Phone: 404-310-6048
  • Fax: 404-255-1831

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number110691
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number9397267
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: