Provider Demographics
NPI:1740291947
Name:COPELAND, KRISTINA M (CRNA)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:M
Last Name:COPELAND
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 1:9331COLLINSVILLE LAKE DR
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39325
Mailing Address - Country:US
Mailing Address - Phone:601-626-8077
Mailing Address - Fax:
Practice Address - Street 1:2124 14TH ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-4040
Practice Address - Country:US
Practice Address - Phone:601-553-6000
Practice Address - Fax:601-553-6115
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR853576367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009935151Medicaid
MS08833291Medicaid
Q66525Medicare UPIN
MS430002129Medicare ID - Type Unspecified