Healthcare Provider Details

I. General information

NPI: 1902135536
Provider Name (Legal Business Name): DEBRA PEDEN CRNFA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2009
Last Update Date: 12/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1214 HOSPITAL ST
GREENVILLE MS
38703-3213
US

IV. Provider business mailing address

1214 HOSPITAL ST
GREENVILLE MS
38703-3213
US

V. Phone/Fax

Practice location:
  • Phone: 662-335-9283
  • Fax: 662-334-6989
Mailing address:
  • Phone: 662-335-9283
  • Fax: 662-334-6989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberR668443
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: