Provider Demographics
NPI:1275837973
Name:YEAGER, KACIE JONES (CRNA)
Entity Type:Individual
Prefix:
First Name:KACIE
Middle Name:JONES
Last Name:YEAGER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 NORTH STATE STREET
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:MS
Mailing Address - Zip Code:39153-0429
Mailing Address - Country:US
Mailing Address - Phone:601-818-6732
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:2011-01-10
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR869339367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP01572994OtherRAILROAD MEDICARE
MS05155267Medicaid
MS302I437793Medicare PIN