Healthcare Provider Details

I. General information

NPI: 1053642801
Provider Name (Legal Business Name): MARYORI CARMONA CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2010
Last Update Date: 10/06/2020
Certification Date: 10/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BOSTON MEDICAL CTR PL DEPT OF DEPARTMENT OF ANESTHESIA
BOSTON MA
02118-2908
US

IV. Provider business mailing address

801 ALBANY ST FL G
BOSTON MA
02119
US

V. Phone/Fax

Practice location:
  • Phone: 617-638-6950
  • Fax: 617-638-6966
Mailing address:
  • Phone: 617-414-5405
  • Fax: 617-414-6031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN2263862
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: