Provider Demographics
NPI:1972508307
Name:CECOLA, MARY (CRNA)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:
Last Name:CECOLA
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:ANN
Other - Last Name:CECOLA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:4502 ORCHID ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-3132
Mailing Address - Country:US
Mailing Address - Phone:318-861-4406
Mailing Address - Fax:318-861-4406
Practice Address - Street 1:2600 GREENWOOD RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-3908
Practice Address - Country:US
Practice Address - Phone:318-212-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA65262-3128367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1698598Medicaid
LA1698598Medicaid
LA430066191Medicare PIN