Healthcare Provider Details

I. General information

NPI: 1770502213
Provider Name (Legal Business Name): DOUGLAS ALLAN LOVERN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 12/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

766 LAKELAND DR STE A
JACKSON MS
39216-4610
US

IV. Provider business mailing address

PO BOX 5371
BRANDON MS
39047-5371
US

V. Phone/Fax

Practice location:
  • Phone: 601-368-3440
  • Fax:
Mailing address:
  • Phone: 601-992-1801
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR801579
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number902973
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: