Provider Demographics
NPI:1700168770
Name:DOTY, STEPHANIE B (CRNA)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:B
Last Name:DOTY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:M
Other - Last Name:BERTRAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 11225
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37401-2225
Mailing Address - Country:US
Mailing Address - Phone:423-892-5602
Mailing Address - Fax:423-892-5838
Practice Address - Street 1:975 E. THIRD STREET
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2147
Practice Address - Country:US
Practice Address - Phone:423-602-8400
Practice Address - Fax:423-602-8401
Is Sole Proprietor?:No
Enumeration Date:2011-09-15
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN161387163W00000X
TNAPN16180367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4308210OtherBLUECROSS BLUESHIELD OF TENNESSEE
GA003116059AMedicaid
AL133675Medicaid
TN4308210OtherBLUECROSS BLUESHIELD OF TENNESSEE