Provider Demographics
NPI:1164076725
Name:DEPEW, MARY (LPN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:DEPEW
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 BRAGAW ST
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-3435
Mailing Address - Country:US
Mailing Address - Phone:907-433-7341
Mailing Address - Fax:907-433-7341
Practice Address - Street 1:1650 BRAGAW ST
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-3435
Practice Address - Country:US
Practice Address - Phone:907-433-7341
Practice Address - Fax:907-433-7393
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-31
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKNURP6127164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse