Healthcare Provider Details

I. General information

NPI: 1891725057
Provider Name (Legal Business Name): DEBRA ANN OSWALT CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 03/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7535 AIRWAYS BLVD
SOUTHAVEN MS
38671-5834
US

IV. Provider business mailing address

4890 DELBRIDGE CT E 4890 DELBRIDGE COURT EAST
OLIVE BRANCH MS
38654-5016
US

V. Phone/Fax

Practice location:
  • Phone: 662-349-7766
  • Fax:
Mailing address:
  • Phone: 662-544-5102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR726958
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: