Healthcare Provider Details

I. General information

NPI: 1356340913
Provider Name (Legal Business Name): MARY SMITH CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 07/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 EAST ST SUITE 1400 LOWE II ANESTHESIOLOGY SERVICE INC
METHUEN MA
01844
US

IV. Provider business mailing address

60 EAST ST SUITE 1400 LOWE II ANESTHESIOLOGY SERVICE INC
METHUEN MA
01844
US

V. Phone/Fax

Practice location:
  • Phone: 978-689-4601
  • Fax: 603-882-0556
Mailing address:
  • Phone: 978-689-4601
  • Fax: 603-882-0556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number030669-21
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number136711
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: