Provider Demographics
NPI:1346294550
Name:COWAN, LEATRICE R (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:LEATRICE
Middle Name:R
Last Name:COWAN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MS
Other - First Name:LEATRICE
Other - Middle Name:R
Other - Last Name:NEELY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:1760 BENNING ST
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38106-6231
Mailing Address - Country:US
Mailing Address - Phone:901-948-1033
Mailing Address - Fax:662-621-5087
Practice Address - Street 1:1970 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-7202
Practice Address - Country:US
Practice Address - Phone:662-624-3534
Practice Address - Fax:662-621-5087
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSA810086367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05287878Medicaid