Provider Demographics
NPI:1285129973
Name:GIDDENS, MARY KOPP (RN, APRN)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:KOPP
Last Name:GIDDENS
Suffix:
Gender:F
Credentials:RN, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2538 OLD HOLTON RD
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-1729
Mailing Address - Country:US
Mailing Address - Phone:478-731-0385
Mailing Address - Fax:
Practice Address - Street 1:2538 OLD HOLTON RD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-1729
Practice Address - Country:US
Practice Address - Phone:478-731-0385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-26
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN183848363LP0200X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty