1659324341 NPI number — DAUREEN K BLOODWORTH CRNA

Table of content: DAUREEN K BLOODWORTH CRNA (NPI 1659324341)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659324341 NPI number — DAUREEN K BLOODWORTH CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLOODWORTH
Provider First Name:
DAUREEN
Provider Middle Name:
K
Provider Name Prefix Text:
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:
KELLUM
Provider Other First Name:
DAUREEN
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRNA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1659324341
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1198
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ABILENE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79604-1198
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
325-670-4220
Provider Business Mailing Address Fax Number:
325-670-4040

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1755 KIRBY PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEMPHIS
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38120-4398
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-725-5846
Provider Business Practice Location Address Fax Number:
901-726-4827
Provider Enumeration Date:
05/17/2006

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:  11951 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: AP127584 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00440722 . This is a "RR MEDICARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3935986 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00527025 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4134142 . This is a "BCBS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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