Provider Demographics
NPI:1083002539
Name:ANDERSON, MARY ELLEN (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 HOOK RD UNIT 41B
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12601-7308
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3 HOOK RD UNIT 41B
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-7308
Practice Address - Country:US
Practice Address - Phone:845-549-2242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-07
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY615403163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse