Provider Demographics
NPI:1790910255
Name:CLOUD NINE ANESTHESIA PA
Entity Type:Organization
Organization Name:CLOUD NINE ANESTHESIA PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:DAVENPORT
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:501-442-1640
Mailing Address - Street 1:191 PLANTATION DR
Mailing Address - Street 2:
Mailing Address - City:MAYFLOWER
Mailing Address - State:AR
Mailing Address - Zip Code:72106-8420
Mailing Address - Country:US
Mailing Address - Phone:501-771-4370
Mailing Address - Fax:501-327-9722
Practice Address - Street 1:9101 KANIS RD STE 300
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6453
Practice Address - Country:US
Practice Address - Phone:501-771-4370
Practice Address - Fax:501-327-9722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-27
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC02646207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty