Basic Information
| Provider Information | |||||||||
| NPI: | 1679913750 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOUGLAS | ||||||||
| FirstName: | MINDY | ||||||||
| MiddleName: | MANNING | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 716 W BROOKHAVEN CIR | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381174504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9018441590 | ||||||||
| FaxNumber: | 9018441592 | ||||||||
| Practice Location | |||||||||
| Address1: | 303 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | BATESVILLE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386068608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8663626963 | ||||||||
| FaxNumber: | 8663624202 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2013 | ||||||||
| LastUpdateDate: | 05/13/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | R876132 | MS | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 21221 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.