Healthcare Provider Details

I. General information

NPI: 1669440020
Provider Name (Legal Business Name): MARY LULGJURAJ CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 09/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44201 DEQUINDRE 400 FSC - PCS
TROY MI
48085-1198
US

IV. Provider business mailing address

130 TOWN CENTER DR STE 203
TROY MI
48084-1744
US

V. Phone/Fax

Practice location:
  • Phone: 248-423-3144
  • Fax:
Mailing address:
  • Phone: 248-585-8221
  • Fax: 248-585-8270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704221264
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: