Provider Demographics
NPI:1932197480
Name:COLYER, MARY ELLEN (CRNA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:COLYER
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:PO BOX 5
Mailing Address - Street 2:
Mailing Address - City:HAZELWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63042-0005
Mailing Address - Country:US
Mailing Address - Phone:314-895-3828
Mailing Address - Fax:636-922-5157
Practice Address - Street 1:10 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:ST PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-1659
Practice Address - Country:US
Practice Address - Phone:314-895-3828
Practice Address - Fax:636-922-5157
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO047943367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO919444109Medicaid
MO430063799OtherRAILROAD MEDICARE
MO028011761Medicare PIN