Provider Demographics
NPI:1316660210
Name:CONZELMAN, MARY JORDAN
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JORDAN
Last Name:CONZELMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:JORDAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3345 MOUNTAINSIDE RD
Mailing Address - Street 2:
Mailing Address - City:VESTAVIA
Mailing Address - State:AL
Mailing Address - Zip Code:35243-5012
Mailing Address - Country:US
Mailing Address - Phone:251-508-7571
Mailing Address - Fax:
Practice Address - Street 1:2700 HIGHWAY 280 S STE 212
Practice Address - Street 2:
Practice Address - City:MOUNTAIN BRK
Practice Address - State:AL
Practice Address - Zip Code:35223-2468
Practice Address - Country:US
Practice Address - Phone:205-878-4368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-26
Last Update Date:2024-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-181941363LF0000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse