Healthcare Provider Details

I. General information

NPI: 1154756658
Provider Name (Legal Business Name): SALLY JO MICHELS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2013
Last Update Date: 01/28/2020
Certification Date: 01/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 865-342-8900
  • Fax: 865-691-0843
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 Number17996
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number3014230
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: