Provider Demographics
NPI:1073174298
Name:DEGANGE, MARY ELLEN (RN)
Entity Type:Individual
Prefix:
First Name:MARY ELLEN
Middle Name:
Last Name:DEGANGE
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 1:1015 E 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99501-2748
Mailing Address - Country:US
Mailing Address - Phone:907-276-6430
Mailing Address - Fax:907-276-3637
Practice Address - Street 1:1015 E 6TH AVE
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99501-2748
Practice Address - Country:US
Practice Address - Phone:907-276-6430
Practice Address - Fax:907-276-3637
Is Sole Proprietor?:No
Enumeration Date:2019-06-27
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK22860163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)