Healthcare Provider Details

I. General information

NPI: 1043222425
Provider Name (Legal Business Name): MARY A KINBAUM CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 01/11/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E MAIN ST
DANVILLE IN
46122-1948
US

IV. Provider business mailing address

PO BOX 3033
INDIANAPOLIS IN
46206-3033
US

V. Phone/Fax

Practice location:
  • Phone: 317-567-2179
  • Fax: 317-567-2191
Mailing address:
  • Phone: 317-567-2180
  • Fax: 317-567-2191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number28080493
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: