=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437502085
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHELLY LAUREN HERETH CRNA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2016
-----------------------------------------------------
Last Update Date | 12/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 MEMORIAL DR
-----------------------------------------------------
City | DALTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30720-2529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-272-6000
-----------------------------------------------------
Fax | 423-602-8401
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 385 DAVIS RIDGE RD
-----------------------------------------------------
City | RINGGOLD
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30736-5900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-645-0902
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | RN200088
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | APN21838
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | RN213029
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------