Provider Demographics
NPI:1477502052
Name:FREIS, MARY (ARNP-C,MS)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:
Last Name:FREIS
Suffix:
Gender:F
Credentials:ARNP-C,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 HAMPTON PARK LN
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-8145
Mailing Address - Country:US
Mailing Address - Phone:772-332-1652
Mailing Address - Fax:
Practice Address - Street 1:2900 VETERANS WAY
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-8007
Practice Address - Country:US
Practice Address - Phone:321-637-3788
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 1366172363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL253050Medicare UPIN