Healthcare Provider Details

I. General information

NPI: 1023848728
Provider Name (Legal Business Name): HEATHER SUSAN VEGA CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2024
Last Update Date: 08/06/2024
Certification Date: 05/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 SHILOH SPGS
JACKSON TN
38305-1315
US

IV. Provider business mailing address

23 SHILOH SPGS
JACKSON TN
38305-1315
US

V. Phone/Fax

Practice location:
  • Phone: 731-358-1008
  • Fax:
Mailing address:
  • Phone: 731-358-1008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number176657
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number64
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number149911
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: