Provider Demographics
NPI:1205097409
Name:PHELPS, EDWARD LEE (CRNA)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:LEE
Last Name:PHELPS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1203 BLUFF RD
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:MS
Mailing Address - Zip Code:38618-6719
Mailing Address - Country:US
Mailing Address - Phone:662-562-7654
Mailing Address - Fax:
Practice Address - Street 1:1203 BLUFF RD
Practice Address - Street 2:
Practice Address - City:COLDWATER
Practice Address - State:MS
Practice Address - Zip Code:38618-6719
Practice Address - Country:US
Practice Address - Phone:662-562-7654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-19
Last Update Date:2015-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR862681367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered