Provider Demographics
NPI:1447270681
Name:NORDAHL, MARY CLARE (CRNA)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:CLARE
Last Name:NORDAHL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MRS
Other - First Name:MARY
Other - Middle Name:CLARE
Other - Last Name:SCHRECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:1212 HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:BLACK RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54615-1906
Mailing Address - Country:US
Mailing Address - Phone:715-284-9691
Mailing Address - Fax:715-284-7166
Practice Address - Street 1:711 W ADAMS ST
Practice Address - Street 2:
Practice Address - City:BLACK RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54615-9108
Practice Address - Country:US
Practice Address - Phone:715-284-5361
Practice Address - Fax:715-284-7166
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI71871367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI71871OtherRN LICENSE
37187OtherAANA REGISTRATION
WI1224OtherAPNP REGISTRATION
WI0002OtherSEQUENCE NUMBER
WI43352400Medicaid
WI71871OtherRN LICENSE