Healthcare Provider Details

I. General information

NPI: 1629068507
Provider Name (Legal Business Name): MARY ANNE MEDLOCK CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY ANNE LAYNE CRNA

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 12/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 JOSEPH E. SANKER BOULEVARD THE UROLOGY CENTER
CINCINNATI OH
45212
US

IV. Provider business mailing address

4549 RAYNOR COURT OUTPATIENT ANESTHESIA SPECIALIST
MASON OH
45040
US

V. Phone/Fax

Practice location:
  • Phone: 513-841-7600
  • Fax: 513-841-7601
Mailing address:
  • Phone: 513-204-5696
  • Fax: 877-284-4283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number202765
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: