Healthcare Provider Details

I. General information

NPI: 1508960295
Provider Name (Legal Business Name): AUDREY DONNA GHATAS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 3RD AVE SE
MAGEE MS
39111-3665
US

IV. Provider business mailing address

PO BOX 669
MOUNT OLIVE MS
39119-0669
US

V. Phone/Fax

Practice location:
  • Phone: 601-849-7173
  • Fax: 601-849-7353
Mailing address:
  • Phone: 601-466-3601
  • Fax: 601-797-9993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR125620
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: