Healthcare Provider Details

I. General information

NPI: 1366687105
Provider Name (Legal Business Name): MARYANN THERESA HENRY CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2008
Last Update Date: 08/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 NORTH 39TH STREET
PHILADELPHIA PA
19104
US

IV. Provider business mailing address

51 NORTH 39TH STREET
PHILADELPHIA PA
19104
US

V. Phone/Fax

Practice location:
  • Phone: 215-662-8244
  • Fax:
Mailing address:
  • Phone: 215-662-8244
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN 506734L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN506734L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: