Healthcare Provider Details

I. General information

NPI: 1295981496
Provider Name (Legal Business Name): AMBER LYNN STAFFORD CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMBER MATHIS CRNA

II. Dates (important events)

Enumeration Date: 08/07/2008
Last Update Date: 11/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

708 W FOREST AVE
JACKSON TN
38301-3901
US

IV. Provider business mailing address

410 N CEDAR BLUFF RD STE 300
KNOXVILLE TN
37923-3632
US

V. Phone/Fax

Practice location:
  • Phone: 731-541-7070
  • Fax:
Mailing address:
  • Phone: 865-342-8900
  • Fax: 865-691-0843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number13597
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: