Provider Demographics
NPI:1457090706
Name:EASTHAM, MARY (APRN)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:EASTHAM
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:COATS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:33688 HONEYSUCKLE LN
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92563-2485
Mailing Address - Country:US
Mailing Address - Phone:818-268-3016
Mailing Address - Fax:
Practice Address - Street 1:25470 MEDICAL CENTER DR STE 102
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-4901
Practice Address - Country:US
Practice Address - Phone:951-698-6090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-02
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95021130363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95021130OtherCALIFORNIA BOARD OF REGISTERED NURSING