Provider Demographics
NPI:1407840564
Name:FLOWERDAY, MARY JEAN (CRNA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JEAN
Last Name:FLOWERDAY
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 1:662 KINGWOOD ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:OR
Mailing Address - Zip Code:97439-9305
Mailing Address - Country:US
Mailing Address - Phone:502-212-9918
Mailing Address - Fax:
Practice Address - Street 1:662 KINGWOOD ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:OR
Practice Address - Zip Code:97439-9305
Practice Address - Country:US
Practice Address - Phone:502-212-9918
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1033209163W00000X
IN28148234163W00000X
KY1637A367500000X
OR087006819RN163W00000X
OR200460022CRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN74397498Medicaid
INCB2010Medicare ID - Type Unspecified
IN74397498Medicaid
ORR141176Medicare PIN