Provider Demographics
NPI:1134470826
Name:RAINER, MARY LOUISE (LM)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:LOUISE
Last Name:RAINER
Suffix:
Gender:F
Credentials:LM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1903 SUNRISE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34950-8101
Mailing Address - Country:US
Mailing Address - Phone:772-475-8560
Mailing Address - Fax:772-801-5293
Practice Address - Street 1:1903 SUNRISE BLVD
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-8101
Practice Address - Country:US
Practice Address - Phone:772-475-8560
Practice Address - Fax:772-801-5293
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-21
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMW264176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006593100Medicaid