Provider Demographics
NPI:1366815383
Name:AZUH, MARY
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:AZUH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1069 LAKEFIELD WALK
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-5758
Mailing Address - Country:US
Mailing Address - Phone:770-356-7597
Mailing Address - Fax:770-726-7108
Practice Address - Street 1:1069 LAKEFIELD WALK
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-5758
Practice Address - Country:US
Practice Address - Phone:770-356-7597
Practice Address - Fax:770-726-7108
Is Sole Proprietor?:No
Enumeration Date:2015-11-12
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003159422A163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003159422AMedicaid