Healthcare Provider Details

I. General information

NPI: 1558320655
Provider Name (Legal Business Name): MARY-JO DRAKE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 10/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

704 HWY 70 E
DICKSON TN
37055-2111
US

IV. Provider business mailing address

PO BOX 291264
NASHVILLE TN
37229-1264
US

V. Phone/Fax

Practice location:
  • Phone: 615-441-4504
  • Fax: 615-620-2323
Mailing address:
  • Phone: 615-620-2330
  • Fax: 615-620-2323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number002039
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPN13743
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN167485
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: