Individual
MARY K HENRICKSEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
CRNA
Contact information
Practice address
580 W COLLEGE AVE, MARQUETTE, MI 49855-2705
(906) 225-3406
(906) 225-3094
Mailing address
E3110 E DEER LAKE RD, AU TRAIN, MI 49806-9512
(906) 892-8530
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
4704081708
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
104135850
—
MI
01
—
430051912
430051912
MI
01
—
43288000
WI MEDICAID PIN
WI
01
—
MH081708
BLUESHIELD PIN
MI
Enumeration date
11/18/2005
Last updated
04/22/2008
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