Healthcare Provider Details

I. General information

NPI: 1487607537
Provider Name (Legal Business Name): CONWAY ELLA CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 07/08/2007
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 11446
KNOXVILLE TN
37939-1446
US

V. Phone/Fax

Practice location:
  • Phone: 423-882-1323
  • Fax:
Mailing address:
  • Phone: 865-602-2117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1108988/4824A
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: