Healthcare Provider Details

I. General information

NPI: 1386674695
Provider Name (Legal Business Name): MARTHA JANE LAIRD CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 10/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1024 KELLY DRIVE VANDYCK AMBULATORY SURGERY CENTER-LODEN VISION
PARIS TN
38242-4500
US

IV. Provider business mailing address

PO BOX 291264
NASHVILLE TN
37229-1264
US

V. Phone/Fax

Practice location:
  • Phone: 731-642-5003
  • Fax: 615-620-2323
Mailing address:
  • Phone: 615-620-2320
  • Fax: 615-620-2323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN039384
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPN08847
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: