Healthcare Provider Details

I. General information

NPI: 1619156486
Provider Name (Legal Business Name): MARY JACQUELINE HERBERT CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2007
Last Update Date: 04/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 MULBERRY ST
SCRANTON PA
18510-2369
US

IV. Provider business mailing address

478 SLOCUM ST
SWOYERSVILLE PA
18704-1947
US

V. Phone/Fax

Practice location:
  • Phone: 570-969-1800
  • Fax:
Mailing address:
  • Phone: 570-287-3225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number078124
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: