Healthcare Provider Details

I. General information

NPI: 1134296627
Provider Name (Legal Business Name): MARY PAT PAMPU CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1910 CHEROKEE AVE SW
CULLMAN AL
35055-5502
US

IV. Provider business mailing address

PO BOX 1547
SEDALIA MO
65302-1547
US

V. Phone/Fax

Practice location:
  • Phone: 256-739-3500
  • Fax:
Mailing address:
  • Phone: 660-826-5960
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1-045655
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: