Healthcare Provider Details

I. General information

NPI: 1548221427
Provider Name (Legal Business Name): SUSAN DALE ROGERS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2006
Last Update Date: 09/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 HUTCHINSON DR
CARTHAGE MS
39051-7588
US

IV. Provider business mailing address

480 HUTCHINSON DR
CARTHAGE MS
39051-7588
US

V. Phone/Fax

Practice location:
  • Phone: 601-416-0652
  • Fax:
Mailing address:
  • Phone: 601-416-0652
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR833525
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number3265
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1-095909
License Number StateAL
# 4
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberPENDING
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: