Healthcare Provider Details

I. General information

NPI: 1154460061
Provider Name (Legal Business Name): BRANDIE JOLIE COCKRELL CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 03/09/2022
Certification Date: 03/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 W MAPLE AVE
SPRINGDALE AR
72764-5335
US

IV. Provider business mailing address

601 W MAPLE AVE STE 503
SPRINGDALE AR
72764-5376
US

V. Phone/Fax

Practice location:
  • Phone: 479-751-5711
  • Fax:
Mailing address:
  • Phone: 479-751-3722
  • Fax: 479-751-1099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2006030339
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberC002652
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: