Provider Demographics
NPI:1205864931
Name:ELLINGWOOD, MARY EPPS (CRNA)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:EPPS
Last Name:ELLINGWOOD
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:616 FAIRFAX RD W
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36608-2930
Mailing Address - Country:US
Mailing Address - Phone:251-342-3799
Mailing Address - Fax:
Practice Address - Street 1:616 FAIRFAX RD W
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-2930
Practice Address - Country:US
Practice Address - Phone:251-342-3799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-100649367500000X
OH177937367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered