Provider Demographics
NPI:1952681280
Name:EZEM, MARY (CRNA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:EZEM
Suffix:
Gender:F
Credentials:CRNA
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Other - First Name:
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Mailing Address - Street 1:99 EAST RIVER DRIVE 5TH FLOOR
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-7301
Mailing Address - Country:US
Mailing Address - Phone:860-282-4022
Mailing Address - Fax:860-289-0742
Practice Address - Street 1:80 SEYMOUR STREET
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06141-0540
Practice Address - Country:US
Practice Address - Phone:860-545-2117
Practice Address - Fax:860-545-1784
Is Sole Proprietor?:No
Enumeration Date:2011-08-18
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT4710367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered