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General NPI Number Information
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NPI Number | 1790850592
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Entity Type | Individual
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Provider Name | MICHELLE S WOMBLE CUSTER CRNA
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Gender | Female
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Dates
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Enumeration Date | 11/21/2006
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Last Update Date | 02/18/2021
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Provider Practice Location Address
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Address Line | 65 WADDELL RD
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City | WOODBURY
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State | GA
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Zip | 30293-4008
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Country | US
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Telephone | 706-573-6769
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Fax | 706-553-3525
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Provider Business Mailing Address
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Address Line | 80 NEWNAN STATION DR STE A
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City | NEWNAN
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State | GA
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Zip | 30265-3194
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Country | US
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Telephone | 770-814-6011
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | RN149265
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License Number State | GA
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