Healthcare Provider Details

I. General information

NPI: 1154340776
Provider Name (Legal Business Name): WILLIAM JODY CROMWELL SR. CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 04/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 E MADISON ST
HOUSTON MS
38851-2417
US

IV. Provider business mailing address

1002 E MADISON ST
HOUSTON MS
38851-2417
US

V. Phone/Fax

Practice location:
  • Phone: 662-456-1163
  • Fax:
Mailing address:
  • Phone: 662-456-1163
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR535672
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: