Provider Demographics
NPI:1972816544
Name:MERRY, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MERRY
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:PO BOX 135
Mailing Address - Street 2:11762 ROUTE 12
Mailing Address - City:REMSEN
Mailing Address - State:NY
Mailing Address - Zip Code:13438
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11762 ROUTE 12
Practice Address - Street 2:
Practice Address - City:REMSEN
Practice Address - State:NY
Practice Address - Zip Code:13438
Practice Address - Country:US
Practice Address - Phone:315-351-6087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-23
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6367916164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse