Provider Demographics
NPI:1942336581
Name:AVERY, CONELIA STACIE (CRNA)
Entity Type:Individual
Prefix:
First Name:CONELIA
Middle Name:STACIE
Last Name:AVERY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 MONTCLAIR DR
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-1879
Mailing Address - Country:US
Mailing Address - Phone:678-371-6105
Mailing Address - Fax:
Practice Address - Street 1:2326 HIGHWAY 34 E STE 100
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-1328
Practice Address - Country:US
Practice Address - Phone:770-683-9840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN144288 CRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered