Provider Demographics
NPI:1841348125
Name:COFFMAN, MARY JENNIFER (CRNA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JENNIFER
Last Name:COFFMAN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1701 PELHAM RD S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36265-3353
Mailing Address - Country:US
Mailing Address - Phone:256-782-4523
Mailing Address - Fax:256-782-4184
Practice Address - Street 1:1701 PELHAM RD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:AL
Practice Address - Zip Code:36265-3353
Practice Address - Country:US
Practice Address - Phone:256-782-4523
Practice Address - Fax:256-782-4184
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1080055367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALQ54204Medicare UPIN