Provider Demographics
NPI:1417974908
Name:BREEDLOVE, MIMI CLEVELAND (CRNA)
Entity Type:Individual
Prefix:
First Name:MIMI
Middle Name:CLEVELAND
Last Name:BREEDLOVE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MIMI
Other - Middle Name:C
Other - Last Name:CLEVELAND BREEDLOVE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 3294
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38803-3294
Mailing Address - Country:US
Mailing Address - Phone:662-377-4394
Mailing Address - Fax:662-377-7045
Practice Address - Street 1:830 S GLOSTER
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801
Practice Address - Country:US
Practice Address - Phone:662-377-4394
Practice Address - Fax:662-377-7045
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2009-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR853077367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS430002113OtherMEDICARE
AL009936796OtherMEDICAID
Q64064Medicare UPIN
MS430002137Medicare ID - Type Unspecified