Provider Demographics
NPI:1114542065
Name:MERSEREAU, GARY JOHN CLINTON SR (BSN, RN)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:JOHN CLINTON
Last Name:MERSEREAU
Suffix:SR
Gender:M
Credentials:BSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 WAYNE DR
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-9024
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:914 S SCHEUBER RD
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-9027
Practice Address - Country:US
Practice Address - Phone:360-330-8785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-16
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60383846163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency