Healthcare Provider Details

I. General information

NPI: 1922306935
Provider Name (Legal Business Name): ALYSON LEE DICKERSON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2011
Last Update Date: 09/13/2021
Certification Date: 09/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 ALCORN DR ANESTHESIA DEPARTMENT
CORINTH MS
38834-9321
US

IV. Provider business mailing address

611 ALCORN DR ANESTHESIA DEPARTMENT
CORINTH MS
38834-9321
US

V. Phone/Fax

Practice location:
  • Phone: 662-293-1000
  • Fax: 662-293-4213
Mailing address:
  • Phone: 662-293-1000
  • Fax: 662-293-4213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR869968
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: