Provider Demographics
NPI:1154708113
Name:CASEY, MARY R (LPN)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:R
Last Name:CASEY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8058 EVESBOROUGH DR
Mailing Address - Street 2:
Mailing Address - City:CLAY
Mailing Address - State:NY
Mailing Address - Zip Code:13041-9139
Mailing Address - Country:US
Mailing Address - Phone:315-572-0752
Mailing Address - Fax:
Practice Address - Street 1:8058 EVESBOROUGH DR
Practice Address - Street 2:
Practice Address - City:CLAY
Practice Address - State:NY
Practice Address - Zip Code:13041-9139
Practice Address - Country:US
Practice Address - Phone:315-572-0752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-29
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10213366372600000X, 164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
No164W00000XNursing Service ProvidersLicensed Practical Nurse