Provider Demographics
NPI:1215973987
Name:HOUSE, MARY COLLEEN (NP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:COLLEEN
Last Name:HOUSE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 LONG AVENUE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:HAMBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14075
Mailing Address - Country:US
Mailing Address - Phone:716-646-5188
Mailing Address - Fax:716-646-5190
Practice Address - Street 1:17 LONG AVENUE
Practice Address - Street 2:SUITE 110
Practice Address - City:HAMBURG
Practice Address - State:NY
Practice Address - Zip Code:14075
Practice Address - Country:US
Practice Address - Phone:716-646-5188
Practice Address - Fax:716-646-5190
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF3331561363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000560585002OtherBLUE CROSS BLUE SHIELD
NY9512110OtherIHA