Healthcare Provider Details

I. General information

NPI: 1083265185
Provider Name (Legal Business Name): TRINH THU WEATHERLY CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2019
Last Update Date: 09/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 13TH ST
GULFPORT MS
39501-2569
US

IV. Provider business mailing address

4500 13TH ST
GULFPORT MS
39501-2515
US

V. Phone/Fax

Practice location:
  • Phone: 228-867-4000
  • Fax:
Mailing address:
  • Phone: 228-867-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number901590
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: