Provider Demographics
NPI:1013021757
Name:FITZGERALD, MARY ANNE (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANNE
Last Name:FITZGERALD
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:PO BOX 2039
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75710-2039
Mailing Address - Country:US
Mailing Address - Phone:903-535-0023
Mailing Address - Fax:903-535-0052
Practice Address - Street 1:815 N BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-4507
Practice Address - Country:US
Practice Address - Phone:903-535-0023
Practice Address - Fax:903-535-0052
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX218756363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX218756OtherNURSE PRACTITIONER LICENS