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General NPI Number Information
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NPI Number | 1790910255
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Entity Type | Organization
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Legal Business Name | CLOUD NINE ANESTHESIA PA
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Dates
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Enumeration Date | 05/27/2009
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Last Update Date | 05/27/2009
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Provider Practice Location Address
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Address Line | 9101 KANIS RD STE 300
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City | LITTLE ROCK
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State | AR
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Zip | 72205-6453
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Country | US
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Telephone | 501-771-4370
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Fax | 501-327-9722
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Provider Business Mailing Address
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Address Line | 191 PLANTATION DR
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City | MAYFLOWER
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State | AR
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Zip | 72106-8420
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Country | US
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Telephone | 501-771-4370
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Fax | 501-327-9722
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Authorized Official
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Title or Position | OWNER
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Name | TRACY LYNN DAVENPORT
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Credential | CRNA
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Telephone | 501-442-1640
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | C02646
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License Number State | AR
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