Provider Demographics
NPI:1346653938
Name:RETZLAFF, MADELINE J (CRNA)
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:J
Last Name:RETZLAFF
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MADELINE
Other - Middle Name:
Other - Last Name:O'DONNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:POST OFFICE BOX 22926
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-2926
Mailing Address - Country:US
Mailing Address - Phone:713-400-2990
Mailing Address - Fax:713-400-2993
Practice Address - Street 1:1635 NORTH LOOP WEST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77008-1593
Practice Address - Country:US
Practice Address - Phone:713-400-2990
Practice Address - Fax:713-400-2993
Is Sole Proprietor?:No
Enumeration Date:2014-06-11
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXCRNA102349363L00000X
TXAP125812367500000X
TX770598367500000X
TXRN770598163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse