Provider Demographics
NPI:1649361007
Name:MUENCH, MARY L (CRNA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:MUENCH
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:PO BOX 423
Mailing Address - Street 2:
Mailing Address - City:GRANGEVILLE
Mailing Address - State:ID
Mailing Address - Zip Code:83530
Mailing Address - Country:US
Mailing Address - Phone:208-413-8744
Mailing Address - Fax:208-983-1921
Practice Address - Street 1:500 PORT DR
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403-1835
Practice Address - Country:US
Practice Address - Phone:509-758-8811
Practice Address - Fax:509-751-1188
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00084325163W00000X
WAAP30004075367500000X
ID18343163W00000X
IDRNA-45A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8041095Medicaid
WA9635053Medicaid
WAAB32682Medicare PIN
ID8041095Medicaid
WAR79021Medicare UPIN