Healthcare Provider Details

I. General information

NPI: 1811619398
Provider Name (Legal Business Name): CODY STEWART CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2022
Last Update Date: 09/13/2022
Certification Date: 09/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER BLVD
COOKEVILLE TN
38501-4294
US

IV. Provider business mailing address

606 BELLA CT
LEBANON TN
37087-5027
US

V. Phone/Fax

Practice location:
  • Phone: 931-528-2541
  • Fax:
Mailing address:
  • Phone: 615-613-5173
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number207191
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number32389
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: