Provider Demographics
NPI:1174554018
Name:HOOVER, MILDRED JAYNE (CRNA)
Entity type:Individual
Prefix:MRS
First Name:MILDRED
Middle Name:JAYNE
Last Name:HOOVER
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 1:11619 FOGGY BANK LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28214-7133
Mailing Address - Country:US
Mailing Address - Phone:704-394-7550
Mailing Address - Fax:
Practice Address - Street 1:10628 PARK ROAD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210
Practice Address - Country:US
Practice Address - Phone:704-667-1000
Practice Address - Fax:704-667-0409
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC035920367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8051801Medicaid
NC8051801Medicaid