Provider Demographics
NPI:1407174204
Name:PUGH, MARY JACQUELINE (ARNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JACQUELINE
Last Name:PUGH
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12955 GORDA CIRCLE WEST
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33773-1712
Mailing Address - Country:US
Mailing Address - Phone:727-510-2564
Mailing Address - Fax:
Practice Address - Street 1:12855 GORDA CIR W
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33773-1712
Practice Address - Country:US
Practice Address - Phone:727-510-2564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-04
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1940192363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily