Provider Demographics
NPI:1265663082
Name:MARY LOU FOLLETT LLC
Entity Type:Organization
Organization Name:MARY LOU FOLLETT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:MARY LOU
Authorized Official - Middle Name:
Authorized Official - Last Name:FOLLETT
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:541-488-1787
Mailing Address - Street 1:2931 DOCTORS PARK DR
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8127
Mailing Address - Country:US
Mailing Address - Phone:541-245-4444
Mailing Address - Fax:
Practice Address - Street 1:2931 DOCTORS PARK DR
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8127
Practice Address - Country:US
Practice Address - Phone:541-245-4444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-28
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20022001NP261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service