1760578843 NPI number — MS. BECKY B EVERETT CRNA

Table of content: MS. BECKY B EVERETT CRNA (NPI 1760578843)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760578843 NPI number — MS. BECKY B EVERETT CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EVERETT
Provider First Name:
BECKY
Provider Middle Name:
B
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
EVERETT
Provider Other First Name:
BECKY
Provider Other Middle Name:
B.
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1760578843
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/13/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
301 GRAYLING BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MADISON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39110
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-918-5311
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2500 N STATE ST
Provider Second Line Business Practice Location Address:
PFS
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39216-4500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-944-4619
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  R558931 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 367500000X , with the licence number: 39359 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0123296 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 118470300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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