Provider Demographics
NPI:1821070392
Name:HENRICKSEN, MARY K (CRNA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:HENRICKSEN
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:E3110 E DEER LAKE RD
Mailing Address - Street 2:
Mailing Address - City:AU TRAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49806-9512
Mailing Address - Country:US
Mailing Address - Phone:906-892-8530
Mailing Address - Fax:
Practice Address - Street 1:580 W COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2705
Practice Address - Country:US
Practice Address - Phone:906-225-3406
Practice Address - Fax:906-225-3094
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704081708367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104135850Medicaid
WI43288000OtherWI MEDICAID PIN
MI430051912Other430051912
MIMH081708OtherBLUESHIELD PIN
MIE26018018Medicare PIN