Provider Demographics
NPI:1265417968
Name:VILLANUEVA, ELIZABETH (CRNA)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:VILLANUEVA
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 1:5115 SHADOW PATH LANE
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047
Mailing Address - Country:US
Mailing Address - Phone:404-788-1667
Mailing Address - Fax:
Practice Address - Street 1:2131 FOUNTAIN DR
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-7024
Practice Address - Country:US
Practice Address - Phone:770-979-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAR041504367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00163808OtherRAILROAD MEDICARE
GA000559754DMedicaid
GAP00163808OtherRAILROAD MEDICARE