Provider Demographics
NPI:1396900189
Name:HUMPHREYS, COURTNEY B (CRNA)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:B
Last Name:HUMPHREYS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:
Other - Last Name:BUTLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:531 ROSELANE ST NW STE 830
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-6979
Mailing Address - Country:US
Mailing Address - Phone:770-794-0477
Mailing Address - Fax:770-794-3108
Practice Address - Street 1:677 CHURCH ST NE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1101
Practice Address - Country:US
Practice Address - Phone:770-794-0477
Practice Address - Fax:770-794-3108
Is Sole Proprietor?:No
Enumeration Date:2008-07-22
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN129258163W00000X
TN13595367500000X
GARN182407367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4187045OtherBLUE CROSS BLUE SHIELD TN
GAN472900OtherWELLCARE (GA MEDICAID)
GA786364128AMedicaid
NC8053491Medicaid
AL108055Medicaid
TN1509499Medicaid
TN1509499Medicaid