Provider Demographics
NPI:1275563314
Name:DOUGLAS, MARY KATHRYN (CNM)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHRYN
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:CNM
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Mailing Address - Street 1:5827 CORPORATE WAY
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-2000
Mailing Address - Country:US
Mailing Address - Phone:561-844-9443
Mailing Address - Fax:561-472-9692
Practice Address - Street 1:3441 SE WILLOGHBY BLVD
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-5060
Practice Address - Country:US
Practice Address - Phone:772-219-1080
Practice Address - Fax:561-472-9690
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2019-03-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLAPRN3403272367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL301318900Medicaid