Provider Demographics
NPI:1417028903
Name:HANCOCK, MARY JANE (CRNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:HANCOCK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 40480
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36640-0480
Mailing Address - Country:US
Mailing Address - Phone:251-470-5890
Mailing Address - Fax:251-471-7925
Practice Address - Street 1:2451 FILLINGIM ST
Practice Address - Street 2:MASTIN 102
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36617-2238
Practice Address - Country:US
Practice Address - Phone:251-470-5890
Practice Address - Fax:251-471-7925
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-079750363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51540552OtherBCBS - MED PK DR
AL51538577OtherBCBS - STANTON RD
MS02332297Medicaid
AL891013340Medicaid
FL308131100Medicaid
AL891013570Medicaid
ALOTH000Medicare UPIN
FL308131100Medicaid