Provider Demographics
NPI:1013240373
Name:CORDELL, HOLLI B (CRNA)
Entity Type:Individual
Prefix:
First Name:HOLLI
Middle Name:B
Last Name:CORDELL
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:P.O. BOX 790213
Mailing Address - Street 2:
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63179-0213
Mailing Address - Country:US
Mailing Address - Phone:225-769-4403
Mailing Address - Fax:225-769-4403
Practice Address - Street 1:7145 PERKINS ROAD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4322
Practice Address - Country:US
Practice Address - Phone:225-769-4403
Practice Address - Fax:225-769-4403
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-17
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN069981 AP05689367500000X
LARN069981/AP05689367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1804011Medicaid
LARN069981 AP05689OtherLA STATE LIC
LA1804011Medicaid