Healthcare Provider Details

I. General information

NPI: 1790305852
Provider Name (Legal Business Name): SARA MICAH EDDLEMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2020
Last Update Date: 03/24/2026
Certification Date: 03/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

848 ADAMS AVE
MEMPHIS TN
38103-2816
US

IV. Provider business mailing address

1593 MCKENAS WAY CV
HERNANDO MS
38632-2203
US

V. Phone/Fax

Practice location:
  • Phone: 866-870-5570
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number27765
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number899452
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number974810-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: