Provider Demographics
NPI:1790850592
Name:WOMBLE CUSTER, MICHELLE S (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:S
Last Name:WOMBLE CUSTER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:S
Other - Last Name:WOMBLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:80 NEWNAN STATION DR
Mailing Address - Street 2:STE A
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-3194
Mailing Address - Country:US
Mailing Address - Phone:770-814-6011
Mailing Address - Fax:
Practice Address - Street 1:65 WADDELL RD
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:GA
Practice Address - Zip Code:30293-4008
Practice Address - Country:US
Practice Address - Phone:706-573-6769
Practice Address - Fax:706-553-3525
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN149265367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q68391Medicare UPIN
43BBCGMMedicare PIN