Healthcare Provider Details

I. General information

NPI: 1801436951
Provider Name (Legal Business Name): CALLIE BRIDGES CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2020
Last Update Date: 01/07/2020
Certification Date: 01/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

969 LAKELAND DR
JACKSON MS
39216-4606
US

IV. Provider business mailing address

PO BOX 235019
MONTGOMERY AL
36123-5019
US

V. Phone/Fax

Practice location:
  • Phone: 601-200-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number894377
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: