Provider Demographics
NPI:1073279659
Name:MARY, ELLEN LEROY
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:LEROY
Last Name:MARY
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 1:9685 E 33RD ST
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85365-5902
Mailing Address - Country:US
Mailing Address - Phone:541-974-1301
Mailing Address - Fax:
Practice Address - Street 1:9685 E 33RD ST
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85365-5902
Practice Address - Country:US
Practice Address - Phone:541-974-1301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-09
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide