Provider Demographics
NPI:1417197450
Name:MCDONOUGH, MARY ELLEN
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:MCDONOUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3189 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NY
Mailing Address - Zip Code:13323-3824
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1900 GENESEE ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-5635
Practice Address - Country:US
Practice Address - Phone:315-797-7050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-04
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY348452163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse