Provider Demographics
NPI:1154385490
Name:COVAULT, AMANDA KIM (CRNA)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:KIM
Last Name:COVAULT
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 1:2510 LAKELAND DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9513
Mailing Address - Country:US
Mailing Address - Phone:601-355-1234
Mailing Address - Fax:601-326-3566
Practice Address - Street 1:2510 LAKELAND DRIVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39232-9513
Practice Address - Country:US
Practice Address - Phone:601-355-1234
Practice Address - Fax:601-326-3566
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-13
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS880864367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08403082Medicaid
MS08403082Medicaid