Provider Demographics
NPI:1942301684
Name:RICHMOND, MARY GRACE (CRNA)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:GRACE
Last Name:RICHMOND
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 1:1926 HEMLOCK HILL
Mailing Address - Street 2:
Mailing Address - City:BLUEFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:24701-4500
Mailing Address - Country:US
Mailing Address - Phone:304-325-6487
Mailing Address - Fax:304-325-6487
Practice Address - Street 1:500 CHERRY STREET
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:WV
Practice Address - Zip Code:24701
Practice Address - Country:US
Practice Address - Phone:304-327-1680
Practice Address - Fax:304-327-1691
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV27869367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0065382000Medicaid
WVRI7165101Medicare ID - Type UnspecifiedMEDICARE