Healthcare Provider Details

I. General information

NPI: 1366524035
Provider Name (Legal Business Name): MARTHA CROSWELL CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 07/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4179 MEADOWDALE DRIVE
WILLIAMSTON MI
48895
US

IV. Provider business mailing address

4179 MEADOWDALE DR
WILLIAMSTON MI
48895-9114
US

V. Phone/Fax

Practice location:
  • Phone: 517-655-7665
  • Fax:
Mailing address:
  • Phone: 517-655-6765
  • Fax: 517-655-6765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704208924
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: