Provider Demographics
NPI:1962541656
Name:HOLBROOK, MARYANN (CRNA)
Entity type:Individual
Prefix:
First Name:MARYANN
Middle Name:
Last Name:HOLBROOK
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 1:4155 LISA DR STE A
Mailing Address - Street 2:
Mailing Address - City:TIPP CITY
Mailing Address - State:OH
Mailing Address - Zip Code:45371-8425
Mailing Address - Country:US
Mailing Address - Phone:937-287-8178
Mailing Address - Fax:937-669-4566
Practice Address - Street 1:81 SYLVANIA DR
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45440-3271
Practice Address - Country:US
Practice Address - Phone:937-431-9531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH46500367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2071681Medicaid
OH2071681Medicaid