Provider Demographics
NPI:1124037296
Name:UDICIOUS, MARY LOU (CRNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LOU
Last Name:UDICIOUS
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:LOUISE
Other - Last Name:UDICIOUS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNP
Mailing Address - Street 1:1088 W BALTIMORE PIKE
Mailing Address - Street 2:SUITE 2500
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-5146
Mailing Address - Country:US
Mailing Address - Phone:610-565-4107
Mailing Address - Fax:610-565-8349
Practice Address - Street 1:1088 W BALTIMORE PIKE
Practice Address - Street 2:SUITE 2500
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-5146
Practice Address - Country:US
Practice Address - Phone:610-565-4107
Practice Address - Fax:610-565-8349
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-06
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP009093363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA104425PF8Medicare PIN
PAQ72657Medicare UPIN