Provider Demographics
NPI:1336365071
Name:KINNEY, MARY BETH (CRNA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
Last Name:KINNEY
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 1:1749 HAMILTON RD STE 102E
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-1941
Mailing Address - Country:US
Mailing Address - Phone:517-482-2118
Mailing Address - Fax:517-482-6280
Practice Address - Street 1:2900 COLLINS RD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-8394
Practice Address - Country:US
Practice Address - Phone:517-975-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704158954367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704158954OtherSTATE LICENSE