Healthcare Provider Details

I. General information

NPI: 1265522999
Provider Name (Legal Business Name): MARY K JENNETT CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4005 ORCHARD DR
MIDLAND MI
48670-0001
US

IV. Provider business mailing address

3519 E POINT DR
BEAVERTON MI
48612-8742
US

V. Phone/Fax

Practice location:
  • Phone: 989-839-3000
  • Fax:
Mailing address:
  • Phone: 989-435-8890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704159661
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: