Provider Demographics
NPI:1174841738
Name:PAUL, MARY B (CNA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:B
Last Name:PAUL
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 COOPER SANDY CV
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:GA
Mailing Address - Zip Code:30004-0801
Mailing Address - Country:US
Mailing Address - Phone:770-330-4256
Mailing Address - Fax:
Practice Address - Street 1:750 COOPER SANDY CV
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:GA
Practice Address - Zip Code:30004-0801
Practice Address - Country:US
Practice Address - Phone:770-330-4256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-06
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACN0028896838374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide