Healthcare Provider Details

I. General information

NPI: 1700074440
Provider Name (Legal Business Name): MARY Y. ANSARI CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2007
Last Update Date: 02/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6308 8TH AVE
KENOSHA WI
53143-5031
US

IV. Provider business mailing address

225 S EXECUTIVE DR
BROOKFIELD WI
53005-4257
US

V. Phone/Fax

Practice location:
  • Phone: 262-656-2011
  • Fax:
Mailing address:
  • Phone: 262-787-4026
  • Fax: 262-782-6040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number72323
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number026133
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: