Provider Demographics
NPI:1396218517
Name:ANDERSON, MARY ELEANOR (RN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELEANOR
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 MONTGOMERY ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13202-2923
Mailing Address - Country:US
Mailing Address - Phone:315-435-3236
Mailing Address - Fax:315-435-3884
Practice Address - Street 1:421 MONTGOMERY ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-2923
Practice Address - Country:US
Practice Address - Phone:315-435-3236
Practice Address - Fax:315-435-3884
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-10
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY299662163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health