=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942336581
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CONELIA STACIE AVERY CRNA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2007
-----------------------------------------------------
Last Update Date | 02/11/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2326 HIGHWAY 34 E STE 100
-----------------------------------------------------
City | NEWNAN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30265-1328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-683-9840
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1115 MONTCLAIR DR
-----------------------------------------------------
City | PEACHTREE CITY
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30269-1879
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-371-6105
-----------------------------------------------------
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 | RN144288 CRNA
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------