Healthcare Provider Details

I. General information

NPI: 1780954511
Provider Name (Legal Business Name): BLAIR BOEVING CANNON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2012
Last Update Date: 01/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1755 KIRBY PKWY STE. 330
MEMPHIS TN
38120-8300
US

IV. Provider business mailing address

4231 BARFIELD RD
MEMPHIS TN
38117-1611
US

V. Phone/Fax

Practice location:
  • Phone: 901-725-5846
  • Fax: 901-726-4827
Mailing address:
  • Phone: 901-359-2512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN0000158063
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: