Provider Demographics
NPI:1003991290
Name:STILLWELL, JIMMY GLENN (CRNA CERTIFIED REGIS)
Entity Type:Individual
Prefix:MR
First Name:JIMMY
Middle Name:GLENN
Last Name:STILLWELL
Suffix:
Gender:M
Credentials:CRNA CERTIFIED REGIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8704 CR 317 SOUTH
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:TX
Mailing Address - Zip Code:75654
Mailing Address - Country:US
Mailing Address - Phone:903-898-2662
Mailing Address - Fax:
Practice Address - Street 1:1007 S WILLIAMS
Practice Address - Street 2:ATLANTA MEMORIAL HOSPITAL
Practice Address - City:ATLANTA
Practice Address - State:TX
Practice Address - Zip Code:75551
Practice Address - Country:US
Practice Address - Phone:903-799-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTX RN 226622367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00C81JOtherBLUE SHIELD GROUP
TX81265UOtherBLUE SHIELD
TX81265UOtherBLUE SHIELD
TX00SD66Medicare ID - Type Unspecified
TX83230HMedicare ID - Type Unspecified