Basic Information
| Provider Information | |||||||||
| NPI: | 1417970070 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PELEGRIN | ||||||||
| FirstName: | ANN | ||||||||
| MiddleName: | I. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 3488, DEPT. 05-003 | ||||||||
| Address2: | |||||||||
| City: | TUPELO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 38803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3343862053 | ||||||||
| FaxNumber: | 3342441830 | ||||||||
| Practice Location | |||||||||
| Address1: | 499 AZALEA DR | ||||||||
| Address2: | |||||||||
| City: | OXFORD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386557901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622347979 | ||||||||
| FaxNumber: | 3342441830 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | R130790 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 00110247 | 05 | MS | MEDICAID |