Provider Demographics
NPI:1508967613
Name:LANDRUM, MARGIE THERESE (CRNA MSN)
Entity Type:Individual
Prefix:
First Name:MARGIE
Middle Name:THERESE
Last Name:LANDRUM
Suffix:
Gender:F
Credentials:CRNA MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1240 FINLEY AVE
Mailing Address - Street 2:
Mailing Address - City:MT ZION
Mailing Address - State:IL
Mailing Address - Zip Code:62549-1019
Mailing Address - Country:US
Mailing Address - Phone:217-864-4717
Mailing Address - Fax:
Practice Address - Street 1:650 W TAYLOR ST
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:IL
Practice Address - Zip Code:62471-1227
Practice Address - Country:US
Practice Address - Phone:618-283-1232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL163W00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Not Answered367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered