Healthcare Provider Details

I. General information

NPI: 1952801938
Provider Name (Legal Business Name): MARY T CHIEREK CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2018
Last Update Date: 02/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 N EDWARD ST
DECATUR IL
62526-4163
US

IV. Provider business mailing address

2300 N EDWARD ST
DECATUR IL
62526-4163
US

V. Phone/Fax

Practice location:
  • Phone: 217-876-2575
  • Fax:
Mailing address:
  • Phone: 217-876-2575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209017259
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: