Provider Demographics
NPI:1619156486
Name:HERBERT, MARY JACQUELINE (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:JACQUELINE
Last Name:HERBERT
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 1:478 SLOCUM ST
Mailing Address - Street 2:
Mailing Address - City:SWOYERSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18704-1947
Mailing Address - Country:US
Mailing Address - Phone:570-287-3225
Mailing Address - Fax:
Practice Address - Street 1:1800 MULBERRY ST
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18510-2369
Practice Address - Country:US
Practice Address - Phone:570-969-1800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-30
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA078124367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1020751570001Medicaid
PA1020751570001Medicaid