Provider Demographics
NPI:1669701926
Name:KING, MARIE GRACE (CRNA)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:GRACE
Last Name:KING
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 1:13523 BARRETT PARKWAY DRIVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63021-3802
Mailing Address - Country:US
Mailing Address - Phone:636-938-1486
Mailing Address - Fax:636-938-1486
Practice Address - Street 1:5319 HOAG DRIVE
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-1494
Practice Address - Country:US
Practice Address - Phone:440-930-6042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-16
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA11303-NA367500000X
OHRN-311442367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00880290OtherRAILROAD MEDICARE
OH3022071Medicaid
OHKL8246511Medicare PIN