Basic Information
| Provider Information | |||||||||
| NPI: | 1568475812 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VERSTRAETE | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 541 OTIS BOWEN DR | ||||||||
| Address2: | |||||||||
| City: | MUNSTER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463214158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199345300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 500 N NAPPANEE ST | ||||||||
| Address2: | SUITE 11B | ||||||||
| City: | ELKHART | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465141503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5745229922 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 28056608 | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.