Healthcare Provider Details

I. General information

NPI: 1225184104
Provider Name (Legal Business Name): MILDRED C DURANT CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 LAIDLEY ST SUITE 606
CHARLESTON WV
25301-1619
US

IV. Provider business mailing address

1824 LOUDEN HEIGHTS RD
CHARLESTON WV
25314-1565
US

V. Phone/Fax

Practice location:
  • Phone: 304-344-0096
  • Fax:
Mailing address:
  • Phone: 304-346-4438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number009308
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: