Healthcare Provider Details

I. General information

NPI: 1972218790
Provider Name (Legal Business Name): MARY BERNADETTE MCCOY CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2023
Last Update Date: 01/16/2023
Certification Date: 01/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4350 DEWEY AVE
OMAHA NE
68105-1017
US

IV. Provider business mailing address

3512 S 105TH ST
OMAHA NE
68124-3606
US

V. Phone/Fax

Practice location:
  • Phone: 402-552-2000
  • Fax:
Mailing address:
  • Phone: 319-290-2158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number143927
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: