Healthcare Provider Details

I. General information

NPI: 1255312617
Provider Name (Legal Business Name): MARY MICHELE SUNSHINE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 POPE AVE
FORT LEAVENWORTH KS
66027-2333
US

IV. Provider business mailing address

13000 UNION RD
MC LOUTH KS
66054-5022
US

V. Phone/Fax

Practice location:
  • Phone: 913-684-6230
  • Fax:
Mailing address:
  • Phone: 913-796-6221
  • Fax: 913-796-6201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number54545
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: