Healthcare Provider Details

I. General information

NPI: 1346625142
Provider Name (Legal Business Name): REBECCA NICOLE CARROLL RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: REBECCA NICOLE GRISCOM CRNA

II. Dates (important events)

Enumeration Date: 07/22/2015
Last Update Date: 11/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3795 OCCONECHEE TRL
CHATTANOOGA TN
37415-4332
US

IV. Provider business mailing address

3795 OCCONECHEE TRL
CHATTANOOGA TN
37415-4332
US

V. Phone/Fax

Practice location:
  • Phone: 423-255-9698
  • Fax:
Mailing address:
  • Phone: 423-255-9698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number20483
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number153484
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: