Provider Demographics
NPI:1942396650
Name:STAFFORD, BEVERLY FULGHAM (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:BEVERLY
Middle Name:FULGHAM
Last Name:STAFFORD
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 1:104 TRACIER CRST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-6236
Mailing Address - Country:US
Mailing Address - Phone:601-924-7732
Mailing Address - Fax:
Practice Address - Street 1:1500 E WOODROW WILSON
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216
Practice Address - Country:US
Practice Address - Phone:601-362-4471
Practice Address - Fax:601-368-4479
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR734107367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered