Provider Demographics
NPI:1275919771
Name:MINTER, MARY (NP-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MINTER
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 NICOLE LN
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-5640
Mailing Address - Country:US
Mailing Address - Phone:404-272-6813
Mailing Address - Fax:
Practice Address - Street 1:414 LUGENIA DR
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-7210
Practice Address - Country:US
Practice Address - Phone:912-537-9355
Practice Address - Fax:912-537-7038
Is Sole Proprietor?:No
Enumeration Date:2015-08-06
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN216867363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily