Healthcare Provider Details

I. General information

NPI: 1275081846
Provider Name (Legal Business Name): CASEY M ELLINGTON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2016
Last Update Date: 04/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 SKYLINE DR
JACKSON TN
38301-3923
US

IV. Provider business mailing address

410 N CEDAR BLUFF RD SUITE 300
KNOXVILLE TN
37923-3623
US

V. Phone/Fax

Practice location:
  • Phone: 731-541-5000
  • Fax:
Mailing address:
  • Phone: 865-342-8900
  • Fax: 865-691-0843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number179740
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number21725
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: