Healthcare Provider Details

I. General information

NPI: 1013145499
Provider Name (Legal Business Name): MARY ALICE HALL CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2009
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9140 HIGHWAY 51 N # SOUTH
SOUTHAVEN MS
38671-1233
US

IV. Provider business mailing address

3340 PLAYERS CLUB PKWY STE 350
MEMPHIS TN
38125-8949
US

V. Phone/Fax

Practice location:
  • Phone: 662-280-8222
  • Fax: 662-280-5541
Mailing address:
  • Phone: 901-844-1590
  • Fax: 844-752-2159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN0000158536
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number14352
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: