=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578141024
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EDNITA CHARZETTE STREET FOUNTAIN DNP, CRNA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2021
-----------------------------------------------------
Last Update Date | 06/16/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1421 N 7TH ST
-----------------------------------------------------
City | TERRE HAUTE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47807-1005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-231-4608
-----------------------------------------------------
Fax | 812-231-4675
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3157 BASIN REFUGE RD
-----------------------------------------------------
City | LUCEDALE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39452-7688
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-947-0366
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 889173
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | 901702
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------