Healthcare Provider Details

I. General information

NPI: 1962864942
Provider Name (Legal Business Name): CAROLYN NELSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2016
Last Update Date: 06/03/2022
Certification Date: 05/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST DEPARTMENT OF ANESTHESIOLOGY S-108
JACKSON MS
39216-4500
US

IV. Provider business mailing address

504 CLINTON CENTER DRIVE CBO-SUITE 4300
CLINTON MS
39056-5610
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-5914
  • Fax: 601-984-5915
Mailing address:
  • Phone: 601-984-5914
  • Fax: 601-984-5915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number29074
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: