1306439922 NPI number — MARY A. CRANE

Table of content: MARY A. CRANE (NPI 1306439922)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306439922 NPI number — MARY A. CRANE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CRANE
Provider First Name:
MARY
Provider Middle Name:
A.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CRANE
Provider Other First Name:
MARY
Provider Other Middle Name:
A.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RPH
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1306439922
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 572
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINONA LAKE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46590-0572
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-268-8154
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1775 E CENTER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WARSAW
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46580-3603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-267-7356
Provider Business Practice Location Address Fax Number:
574-267-1599
Provider Enumeration Date:
02/15/2021

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: 183500000X , with the licence number:  26016113A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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