Healthcare Provider Details

I. General information

NPI: 1063956589
Provider Name (Legal Business Name): JENNIFER DICKENS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2016
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 29TH AVE N STE 202
NASHVILLE TN
37203-1448
US

IV. Provider business mailing address

110 29TH AVE N STE 202
NASHVILLE TN
37203-1448
US

V. Phone/Fax

Practice location:
  • Phone: 615-327-7885
  • Fax: 615-866-5165
Mailing address:
  • Phone: 615-327-7885
  • Fax: 615-866-5165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number124766
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: