Healthcare Provider Details

I. General information

NPI: 1841282134
Provider Name (Legal Business Name): LISA KAY ROOT CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 04/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 MED TECH PKWY
JOHNSON CITY TN
37604-2253
US

IV. Provider business mailing address

1009 LARK ST STE 2
JOHNSON CITY TN
37604-8218
US

V. Phone/Fax

Practice location:
  • Phone: 423-610-1020
  • Fax:
Mailing address:
  • Phone: 423-283-0776
  • Fax: 423-968-5697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN0000114257
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: