Provider Demographics
NPI:1073856811
Name:NOTTINGHAM, MARY (NP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:NOTTINGHAM
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 1:1119 2ND ST SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24016-4710
Mailing Address - Country:US
Mailing Address - Phone:540-981-1246
Mailing Address - Fax:
Practice Address - Street 1:1119 2ND ST SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-4710
Practice Address - Country:US
Practice Address - Phone:540-981-1246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-30
Last Update Date:2013-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024060051363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology