Provider Demographics
NPI:1467518811
Name:ALLCOTT, MARY ALICE (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ALICE
Last Name:ALLCOTT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 BELLEVUE RD
Mailing Address - Street 2:SUITE 21-A
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-2885
Mailing Address - Country:US
Mailing Address - Phone:478-275-7202
Mailing Address - Fax:478-274-8418
Practice Address - Street 1:510 EAST OGLETHORPE HIGHWAY
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-2825
Practice Address - Country:US
Practice Address - Phone:912-369-7546
Practice Address - Fax:912-876-3396
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN052669363LF0000X, 363LA2200X, 363LP2300X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA130497891BMedicaid
GARN052669OtherGEORGIA LICENSE
GA348466OtherWELLCARE NUMBER
GAP00228955OtherRAILROAD MEDICARE
GA10064224OtherAMERIGROUP NUMBER
GAQ44016Medicare UPIN
GA348466OtherWELLCARE NUMBER