Provider Demographics
NPI:1265762454
Name:KOONCE, CAILEY SCRUGGS (CRNA)
Entity type:Individual
Prefix:
First Name:CAILEY
Middle Name:SCRUGGS
Last Name:KOONCE
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 1:101 SIVLEY RD SW
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-4421
Mailing Address - Country:US
Mailing Address - Phone:256-265-9639
Mailing Address - Fax:256-265-7767
Practice Address - Street 1:101 SIVLEY RD SW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-4421
Practice Address - Country:US
Practice Address - Phone:256-265-9639
Practice Address - Fax:256-265-7767
Is Sole Proprietor?:No
Enumeration Date:2010-01-11
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9297226367500000X
TX811702367500000X
AL1-109346367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001796600Medicaid
AL592-10007OtherBLUE CROSS BLUE SHIELD
AL115859Medicaid
FLY02CPOtherBLUE CROSS BLUE SHIELD
FLCS234ZMedicare PIN