Healthcare Provider Details

I. General information

NPI: 1407843519
Provider Name (Legal Business Name): PATRICIA L DOUGLAS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 02/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 DEVONIA ST
HARRIMAN TN
37748-2009
US

IV. Provider business mailing address

PO BOX 51406
KNOXVILLE TN
37950-1406
US

V. Phone/Fax

Practice location:
  • Phone: 865-882-1323
  • Fax:
Mailing address:
  • Phone: 865-524-2739
  • Fax: 865-524-2739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN33794
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: