1033280664 NPI number — JILL A NESLEY CRNA

Table of content: JILL A NESLEY CRNA (NPI 1033280664)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033280664 NPI number — JILL A NESLEY CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NESLEY
Provider First Name:
JILL
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033280664
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 28068
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHATTANOOGA
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37424-8068
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-899-1033
Provider Business Mailing Address Fax Number:
423-892-5838

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1120 15TH ST
Provider Second Line Business Practice Location Address:
ROOM 2144
Provider Business Practice Location Address City Name:
AUGUSTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30912-0004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-721-3873
Provider Business Practice Location Address Fax Number:
706-721-7763
Provider Enumeration Date:
11/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  RN125668 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 550789920 . This is a "TRICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 430077892 . This is a "RRMEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000677036C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 339326 . This is a "WELLCARE CMO" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000677036B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GAN202 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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