Provider Demographics
NPI:1083019939
Name:STOCK, MARY (LMT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:STOCK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 SE CONVENIENCE BLVD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50021-9432
Mailing Address - Country:US
Mailing Address - Phone:515-554-2140
Mailing Address - Fax:515-635-0009
Practice Address - Street 1:2701 SE CONVENIENCE BLVD
Practice Address - Street 2:SUITE 3
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50021-9432
Practice Address - Country:US
Practice Address - Phone:515-554-2140
Practice Address - Fax:515-635-0009
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-04
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA067464171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor