Provider Demographics
NPI:1003146606
Name:CHILDRESS, EMILY SUMRALL (CRNA)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:SUMRALL
Last Name:CHILDRESS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:NICOLE
Other - Last Name:SUMRALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-1000
Mailing Address - Fax:
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-04
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR872306367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01588596Medicaid
MSP01500390OtherRAILROAD MEDICARE
MS01588596Medicaid