Healthcare Provider Details

I. General information

NPI: 1114370467
Provider Name (Legal Business Name): KATIE ELIZABETH MAYBERGER CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2016
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 GRAND CONCOURSE
BRONX NY
10457
US

IV. Provider business mailing address

14 SCHOOL ST
RONKONKOMA NY
11779-2210
US

V. Phone/Fax

Practice location:
  • Phone: 718-466-8153
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN2291273
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number558973
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: