Provider Demographics
NPI:1396771226
Name:HADLEY, CLYDE H (CRNA)
Entity type:Individual
Prefix:
First Name:CLYDE
Middle Name:H
Last Name:HADLEY
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:PO BOX 23145
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-3145
Mailing Address - Country:US
Mailing Address - Phone:954-545-0337
Mailing Address - Fax:954-545-3497
Practice Address - Street 1:129 JEFFERSON DAVIS BLVD
Practice Address - Street 2:
Practice Address - City:NATCHEZ
Practice Address - State:MS
Practice Address - Zip Code:39120-5103
Practice Address - Country:US
Practice Address - Phone:601-445-6248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR869711163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP00132031OtherRAILROAD MEDICARE
MS08527368Medicaid