Provider Demographics
NPI:1710914387
Name:WILMOTH, EDNA MAE (CRNA)
Entity Type:Individual
Prefix:MS
First Name:EDNA
Middle Name:MAE
Last Name:WILMOTH
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 1:117 DRAKE LN
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71913-7874
Mailing Address - Country:US
Mailing Address - Phone:501-760-3200
Mailing Address - Fax:501-760-5005
Practice Address - Street 1:117 DRAKE LN
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913-7874
Practice Address - Country:US
Practice Address - Phone:501-760-3200
Practice Address - Fax:501-760-5005
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR 32179 / C00549367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered