Provider Demographics
NPI:1477131290
Name:MARES, MARY GRACE (NP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:GRACE
Last Name:MARES
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3059 ANDERSON PL
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-1601
Mailing Address - Country:US
Mailing Address - Phone:404-933-3826
Mailing Address - Fax:
Practice Address - Street 1:141 CENTRE ST
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-6043
Practice Address - Country:US
Practice Address - Phone:803-534-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-01
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN290035363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily