Individual
MARY E KOTERBA
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
CRNA
Contact information
Practice address
3301 BROADWAY ST, QUINCY, IL 62301-3713
(217) 222-6550
Mailing address
1025 MAINE ST, QUINCY, IL 62301-4096
(217) 222-6550
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
118799
MO
367500000X
Certified Registered Nurse Anesthetist
Primary
209006248
IL
367500000X
Certified Registered Nurse Anesthetist
4704351565
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
4704351565
MI LICENSE
MI
05
—
915820112
—
MO
Enumeration date
01/16/2006
Last updated
02/16/2021
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