Provider Demographics
NPI:1568475812
Name:VERSTRAETE, MARY J (CRNA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:J
Last Name:VERSTRAETE
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 1:541 OTIS BOWEN DR
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-4158
Mailing Address - Country:US
Mailing Address - Phone:219-934-5300
Mailing Address - Fax:
Practice Address - Street 1:500 N NAPPANEE ST
Practice Address - Street 2:SUITE 11B
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-1503
Practice Address - Country:US
Practice Address - Phone:574-522-9922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28056608367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
INCB9080IMedicare ID - Type Unspecified