Provider Demographics
NPI:1588717367
Name:TOLA, MARY (CRNP)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:TOLA
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12404 BUTLER DR NW
Mailing Address - Street 2:
Mailing Address - City:LAVALE
Mailing Address - State:MD
Mailing Address - Zip Code:21502-6026
Mailing Address - Country:US
Mailing Address - Phone:301-759-3968
Mailing Address - Fax:
Practice Address - Street 1:12502 WILLOWBROOK RD
Practice Address - Street 2:SUITE 300
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-6491
Practice Address - Country:US
Practice Address - Phone:240-964-8787
Practice Address - Fax:240-964-8687
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR062454363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD621091100Medicaid