Provider Demographics
NPI:1558354548
Name:CRODELLE, MARY (CRNA)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:
Last Name:CRODELLE
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 1:43 KENSICO DR
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:MOUNT KISCO
Mailing Address - State:NY
Mailing Address - Zip Code:10549-1009
Mailing Address - Country:US
Mailing Address - Phone:914-666-8866
Mailing Address - Fax:914-666-6777
Practice Address - Street 1:105 MARYS AVE
Practice Address - Street 2:BENEDICTINE HOSPITAL
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-5848
Practice Address - Country:US
Practice Address - Phone:845-334-3080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-25
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY274347367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS55662Medicare UPIN
NYR1B481Medicare ID - Type Unspecified