Provider Demographics
NPI:1336706316
Name:HESIDENCE, MARY KATHLEEN (FNP-C)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:KATHLEEN
Last Name:HESIDENCE
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:KAY
Other - Last Name:MATTHEWS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5830 ASBY WAY
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-0640
Mailing Address - Country:US
Mailing Address - Phone:412-478-9710
Mailing Address - Fax:
Practice Address - Street 1:81 NORTHSIDE DR
Practice Address - Street 2:#100
Practice Address - City:DAWSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:30040
Practice Address - Country:US
Practice Address - Phone:412-478-9710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-24
Last Update Date:2019-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN249265363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily