Healthcare Provider Details

I. General information

NPI: 1538106802
Provider Name (Legal Business Name): ALLENE CRAVEN JOLLY CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3050 CORDER DR
CORINTH MS
38834-6210
US

IV. Provider business mailing address

3050 CORDER DR
CORINTH MS
38834-6210
US

V. Phone/Fax

Practice location:
  • Phone: 662-284-9995
  • Fax: 662-284-9920
Mailing address:
  • Phone: 662-284-9995
  • Fax: 662-284-9920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP2723082
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR529109
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: