Provider Demographics
NPI:1073878765
Name:GURA, MARY JO (RN, WHNP-BC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JO
Last Name:GURA
Suffix:
Gender:F
Credentials:RN, WHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10215 AUBURN PARK DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-2387
Mailing Address - Country:US
Mailing Address - Phone:260-490-2229
Mailing Address - Fax:260-490-3807
Practice Address - Street 1:10215 AUBURN PARK DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-2387
Practice Address - Country:US
Practice Address - Phone:260-490-2229
Practice Address - Fax:260-490-3807
Is Sole Proprietor?:No
Enumeration Date:2012-07-09
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28161564A163W00000X
IN71004092A363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201091680Medicaid
INM400074460Medicare PIN