Healthcare Provider Details

I. General information

NPI: 1023073012
Provider Name (Legal Business Name): MILLICENT COOK CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 09/09/2022
Certification Date: 09/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6019 WALNUT GROVE RD
MEMPHIS TN
38120-2113
US

IV. Provider business mailing address

415 S 28TH AVE
HATTIESBURG MS
39401-7246
US

V. Phone/Fax

Practice location:
  • Phone: 901-226-5000
  • Fax:
Mailing address:
  • Phone: 601-261-3606
  • Fax: 601-579-5240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberSRA-100010
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR759483
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number31935
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: