Basic Information
| Provider Information | |||||||||
| NPI: | 1871551127 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOOLSBY | ||||||||
| FirstName: | LYNN | ||||||||
| MiddleName: | SCOTT | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2844 TWIN PINE RD | ||||||||
| Address2: | |||||||||
| City: | THOMSON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 308246513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065970815 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 206 ELIZABETH AVE | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296463815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642278242 | ||||||||
| FaxNumber: | 8642278148 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 01/08/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN149526 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 2976 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | GAN546 | 05 | SC | MEDICAID |