Healthcare Provider Details

I. General information

NPI: 1346294550
Provider Name (Legal Business Name): LEATRICE R COWAN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LEATRICE R NEELY CRNA

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 06/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1970 HOSPITAL DR
CLARKSDALE MS
38614-7202
US

IV. Provider business mailing address

1760 BENNING ST
MEMPHIS TN
38106-6231
US

V. Phone/Fax

Practice location:
  • Phone: 662-624-3534
  • Fax: 662-621-5087
Mailing address:
  • Phone: 901-948-1033
  • Fax: 662-621-5087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberA810086
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: