Healthcare Provider Details

I. General information

NPI: 1689640518
Provider Name (Legal Business Name): CORY F BLACKWELL CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 04/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2341 MCCALLIE AVE SUITE 402
CHATTANOOGA TN
37404-3239
US

IV. Provider business mailing address

PO BOX 73709
NEWNAN GA
30271-3709
US

V. Phone/Fax

Practice location:
  • Phone: 423-698-3309
  • Fax: 423-624-6355
Mailing address:
  • Phone: 770-251-2060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN103349
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPN09974
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN111991
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: