Provider Demographics
NPI:1760748925
Name:DOUGLAS, KATY B (CRNA)
Entity Type:Individual
Prefix:
First Name:KATY
Middle Name:B
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KATY
Other - Middle Name:L
Other - Last Name:BASKIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 3549
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37404-0549
Mailing Address - Country:US
Mailing Address - Phone:423-698-3309
Mailing Address - Fax:423-624-6355
Practice Address - Street 1:2341 MCCALLIE AVE
Practice Address - Street 2:SUITE 402
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-3239
Practice Address - Country:US
Practice Address - Phone:423-698-3309
Practice Address - Fax:423-624-6355
Is Sole Proprietor?:No
Enumeration Date:2012-04-02
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN16546367500000X
TNRN153283367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
P01054337OtherRAILROAD MEDICARE
TN1528119Medicaid
TN4323069OtherBCBS OF TN
TN1528119Medicaid