Healthcare Provider Details

I. General information

NPI: 1356410401
Provider Name (Legal Business Name): JO ELLEN MARTIN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JO ELLEN COLLIER CRNA

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 MEDICAL CENTER DRIVE NORTH MISS MEDICAL CENTER WEST POINT
WEST POINT MS
39773
US

IV. Provider business mailing address

1417 TAYLOR THURSTON RD
COLUMBUS MS
39701
US

V. Phone/Fax

Practice location:
  • Phone: 662-495-2300
  • Fax:
Mailing address:
  • Phone: 662-328-7067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR570613
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: