Healthcare Provider Details

I. General information

NPI: 1407245988
Provider Name (Legal Business Name): MARY W NASH CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARY W LUTHER CRNA

II. Dates (important events)

Enumeration Date: 01/21/2015
Last Update Date: 02/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

880 RICHLAND EAST DR
RICHLAND MS
39218-9532
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-5900
  • Fax:
Mailing address:
  • Phone: 662-402-9443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR874735
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: