Provider Demographics
NPI:1619971421
Name:MCDOUGLE, MARY LYNNE (CRNA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LYNNE
Last Name:MCDOUGLE
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:PO BOX 120
Mailing Address - Street 2:202 MAPLE AVE STE B
Mailing Address - City:CHESTERTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21620-0120
Mailing Address - Country:US
Mailing Address - Phone:410-810-7055
Mailing Address - Fax:410-810-7054
Practice Address - Street 1:100 BROWN ST
Practice Address - Street 2:
Practice Address - City:CHESTERTOWN
Practice Address - State:MD
Practice Address - Zip Code:21620-1435
Practice Address - Country:US
Practice Address - Phone:410-778-3300
Practice Address - Fax:410-810-7180
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC000388367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCF232 0013OtherBCBS
MD68639503OtherBCBS MD
VA8938938Medicaid