=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447717681
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARGARET ALLEN MERGENTHAL CRNA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/25/2019
-----------------------------------------------------
Last Update Date | 08/19/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1968 PEACHTREE RD NW
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30309-1281
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-814-1612
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2696 CARLTON PL NE
-----------------------------------------------------
City | BROOKHAVEN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30319-3622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | RN289573
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 705566
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------