Healthcare Provider Details

I. General information

NPI: 1346286499
Provider Name (Legal Business Name): CHARLESTINE CARTER CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 11/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25117 HIGHWAY 15
UNION MS
39365-9088
US

IV. Provider business mailing address

PO BOX 2106
MERIDIAN MS
39302-2106
US

V. Phone/Fax

Practice location:
  • Phone: 601-774-8214
  • Fax: 601-774-8379
Mailing address:
  • Phone: 601-703-9506
  • Fax: 601-703-3264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR794408
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: