Provider Demographics
NPI:1093034613
Name:HYDE, MARY M (RN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:HYDE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 CHANTILLY LN
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-4620
Mailing Address - Country:US
Mailing Address - Phone:585-223-3003
Mailing Address - Fax:
Practice Address - Street 1:4 CHANTILLY LN
Practice Address - Street 2:
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450-4620
Practice Address - Country:US
Practice Address - Phone:585-223-3003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-21
Last Update Date:2010-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY492549-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY492549-1OtherRN