Provider Demographics
NPI:1073653770
Name:EARHART, MARY ALICE (LM RN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ALICE
Last Name:EARHART
Suffix:
Gender:F
Credentials:LM RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55100 RUE MARANDE
Mailing Address - Street 2:
Mailing Address - City:THERMAL
Mailing Address - State:CA
Mailing Address - Zip Code:92274-9231
Mailing Address - Country:US
Mailing Address - Phone:760-392-5046
Mailing Address - Fax:760-347-8276
Practice Address - Street 1:55100 RUE MARANDE
Practice Address - Street 2:
Practice Address - City:THERMAL
Practice Address - State:CA
Practice Address - Zip Code:92274-9231
Practice Address - Country:US
Practice Address - Phone:760-392-5046
Practice Address - Fax:760-347-8276
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA361608163WA0400X, 163WC1500X, 163WM0102X, 163WP1700X, 163WW0101X
CALM96176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
Not Answered163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
Not Answered163WM0102XNursing Service ProvidersRegistered NurseMaternal Newborn
Not Answered163WP1700XNursing Service ProvidersRegistered NursePerinatal
Not Answered163WW0101XNursing Service ProvidersRegistered NurseWomen's Health Care, Ambulatory
Not Answered176B00000XOther Service ProvidersMidwife