Healthcare Provider Details

I. General information

NPI: 1407840564
Provider Name (Legal Business Name): MARY JEAN FLOWERDAY CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 07/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

662 KINGWOOD ST
FLORENCE OR
97439-9305
US

IV. Provider business mailing address

662 KINGWOOD ST
FLORENCE OR
97439-9305
US

V. Phone/Fax

Practice location:
  • Phone: 502-212-9918
  • Fax:
Mailing address:
  • Phone: 502-212-9918
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1033209
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28148234
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1637A
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number087006819RN
License Number StateOR
# 5
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number200460022CRNA
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: