Provider Demographics
NPI:1154300382
Name:JOHNSON, MARY ANNE (CRNA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANNE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MARY ANNE
Other - Middle Name:ANNE
Other - Last Name:KUMMER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:1101 W UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48307-1863
Mailing Address - Country:US
Mailing Address - Phone:248-652-5341
Mailing Address - Fax:248-652-5861
Practice Address - Street 1:1101 W UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307-1863
Practice Address - Country:US
Practice Address - Phone:248-652-5354
Practice Address - Fax:248-652-5861
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704120956367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104537338Medicaid
F36455195OtherMEDICARE CHMC PTAN
MIMR120956OtherBLUE CROSS OF MI
11802470OtherCAQH
MIN24360226Medicare ID - Type Unspecified
MIMR120956OtherBLUE CROSS OF MI