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General NPI Number Information
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NPI Number | 1487667838
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Entity Type | Individual
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Provider Name | MARY M MCMILLAN CRNA
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Gender | Female
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Dates
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Enumeration Date | 08/15/2006
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Last Update Date | 03/10/2021
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Provider Practice Location Address
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Address Line | 2799 W GRAND BLVD
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City | DETROIT
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State | MI
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Zip | 48202-2608
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Country | US
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Telephone | 586-610-5523
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Fax |
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Provider Business Mailing Address
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Address Line | 8762 MARQUETTE DR
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City | GROSSE ILE
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State | MI
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Zip | 48138-1566
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Country | US
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Telephone | 734-755-8123
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | 4704138586
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License Number State | MI
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