Basic Information
| Provider Information | |||||||||
| NPI: | 1629031349 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TOLER | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | PHYLLIS | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 235019 | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361235019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3342791450 | ||||||||
| FaxNumber: | 3342791660 | ||||||||
| Practice Location | |||||||||
| Address1: | 1601 WATSON BLVD | ||||||||
| Address2: | |||||||||
| City: | WARNER ROBINS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310933431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4783290051 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2006 | ||||||||
| LastUpdateDate: | 12/23/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN047511 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 000519494C | 05 | GA | MEDICAID | 376552 | 01 | GA | STATE MERIT | OTHER | 430053698 | 01 | GA | PALMETTO | OTHER |