Healthcare Provider Details

I. General information

NPI: 1154300382
Provider Name (Legal Business Name): MARY ANNE JOHNSON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY ANNE ANNE KUMMER CRNA

II. Dates (important events)

Enumeration Date: 01/16/2006
Last Update Date: 10/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 W UNIVERSITY DR
ROCHESTER MI
48307-1863
US

IV. Provider business mailing address

1101 W UNIVERSITY DR
ROCHESTER MI
48307-1863
US

V. Phone/Fax

Practice location:
  • Phone: 248-652-5354
  • Fax: 248-652-5861
Mailing address:
  • Phone: 248-652-5341
  • Fax: 248-652-5861

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704120956
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: