Healthcare Provider Details

I. General information

NPI: 1659867109
Provider Name (Legal Business Name): MARY ANN CROUSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2018
Last Update Date: 09/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 SKYLINE DR
JACKSON TN
38301-3923
US

IV. Provider business mailing address

PO BOX 400
JACKSON TN
38302-0400
US

V. Phone/Fax

Practice location:
  • Phone: 731-541-7070
  • Fax:
Mailing address:
  • Phone: 731-425-5752
  • Fax: 731-422-5743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number24759
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: