Provider Demographics
NPI:1760578843
Name:EVERETT, BECKY B (CRNA)
Entity Type:Individual
Prefix:MS
First Name:BECKY
Middle Name:B
Last Name:EVERETT
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MS
Other - First Name:BECKY
Other - Middle Name:B
Other - Last Name:EVERETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:301 GRAYLING BLVD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110
Mailing Address - Country:US
Mailing Address - Phone:601-918-5311
Mailing Address - Fax:
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:PFS
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-944-4619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR558931367500000X
MS39359367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0123296Medicaid
MS0123296Medicaid
MS302I438585Medicare PIN