1821070392 NPI number — MARY K HENRICKSEN CRNA

Table of content: MARY K HENRICKSEN CRNA (NPI 1821070392)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821070392 NPI number — MARY K HENRICKSEN CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENRICKSEN
Provider First Name:
MARY
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1821070392
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
E3110 E DEER LAKE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AU TRAIN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49806-9512
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
906-892-8530
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
580 W COLLEGE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARQUETTE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49855-2705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-225-3406
Provider Business Practice Location Address Fax Number:
906-225-3094
Provider Enumeration Date:
11/18/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  4704081708 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 104135850 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 43288000 . This is a "WI MEDICAID PIN" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 430051912 . This is a "430051912" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: MH081708 . This is a "BLUESHIELD PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".