Provider Demographics
NPI:1023204153
Name:LARUE, MARY K (RN)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:K
Last Name:LARUE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 EASTMAN EST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14622-1747
Mailing Address - Country:US
Mailing Address - Phone:585-266-4631
Mailing Address - Fax:
Practice Address - Street 1:118 EASTMAN EST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14622-1747
Practice Address - Country:US
Practice Address - Phone:585-266-4631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-21
Last Update Date:2007-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY297133-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02851467Medicaid