Healthcare Provider Details

I. General information

NPI: 1023114766
Provider Name (Legal Business Name): MARY R TUNNESSEN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 04/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 E BROWN ST
E STROUDSBURG PA
18301-3006
US

IV. Provider business mailing address

3998 FAIR RIDGE DR STE 300
FAIRFAX VA
22033-2921
US

V. Phone/Fax

Practice location:
  • Phone: 570-421-4000
  • Fax:
Mailing address:
  • Phone: 703-295-9360
  • Fax: 703-766-9725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN318234L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: