Healthcare Provider Details

I. General information

NPI: 1467906933
Provider Name (Legal Business Name): VICTORIA LEIGH EADS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2016
Last Update Date: 11/18/2024
Certification Date: 11/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 S 31ST ST
TEMPLE TX
76508-2300
US

IV. Provider business mailing address

1480 CONCORD PKWY NORTH SUITE 350 1168
CONCORD NC
28025
US

V. Phone/Fax

Practice location:
  • Phone: 254-724-2111
  • Fax:
Mailing address:
  • Phone: 832-689-6955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberRNA243045
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP131681
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0024182849
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: