Provider Demographics
NPI:1265453153
Name:FADA, MARYANN NANCY (CRNA)
Entity Type:Individual
Prefix:
First Name:MARYANN
Middle Name:NANCY
Last Name:FADA
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 1:614 W WHITE BEAR DR
Mailing Address - Street 2:
Mailing Address - City:SUMMIT HILL
Mailing Address - State:PA
Mailing Address - Zip Code:18250-1741
Mailing Address - Country:US
Mailing Address - Phone:570-645-2374
Mailing Address - Fax:
Practice Address - Street 1:700 E NORWEGIAN ST
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-2710
Practice Address - Country:US
Practice Address - Phone:570-621-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN190268L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered