Provider Demographics
NPI:1730287723
Name:MCDANIEL, CARLY B (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:CARLY
Middle Name:B
Last Name:MCDANIEL
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 1:221 BOXWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-8004
Mailing Address - Country:US
Mailing Address - Phone:601-942-1594
Mailing Address - Fax:
Practice Address - Street 1:221 BOXWOOD CIR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39047-8004
Practice Address - Country:US
Practice Address - Phone:601-942-1594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR859306367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS430002234Medicare PIN