Provider Demographics
NPI:1306595632
Name:DECLAN, MARY JEANNETTE (RN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JEANNETTE
Last Name:DECLAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 E CARSON ST UNIT 105
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90745-2726
Mailing Address - Country:US
Mailing Address - Phone:424-264-9484
Mailing Address - Fax:
Practice Address - Street 1:555 E CARSON ST UNIT 105
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90745-2726
Practice Address - Country:US
Practice Address - Phone:424-264-9484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-23
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95222989163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse