Provider Demographics
NPI:1093242422
Name:LALA LAND ANESTHESIA, LLC
Entity Type:Organization
Organization Name:LALA LAND ANESTHESIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:C
Authorized Official - Last Name:CONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:229-392-8840
Mailing Address - Street 1:276 BELFLOWER RD
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-1607
Mailing Address - Country:US
Mailing Address - Phone:229-392-8840
Mailing Address - Fax:478-333-6117
Practice Address - Street 1:276 BELFLOWER RD
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-1607
Practice Address - Country:US
Practice Address - Phone:229-392-8840
Practice Address - Fax:478-333-6117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN167296367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty