Provider Demographics
NPI:1649203290
Name:GONZALES, MARY L (CRNA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:GONZALES
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:L
Other - Last Name:HULLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:4500 MEMORIAL DRIVE
Mailing Address - Street 2:ANESTHESIA DEPT
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223
Mailing Address - Country:US
Mailing Address - Phone:618-257-4076
Mailing Address - Fax:
Practice Address - Street 1:4500 MEMORIAL DRIVE
Practice Address - Street 2:ANESTHESIA DEPT
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223
Practice Address - Country:US
Practice Address - Phone:618-257-4076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL203022Medicare ID - Type Unspecified