Provider Demographics
NPI:1477806891
Name:LEGER, MARY SUSAN
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:SUSAN
Last Name:LEGER
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 1:107 CRISTINE CT
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-4713
Mailing Address - Country:US
Mailing Address - Phone:850-496-0951
Mailing Address - Fax:
Practice Address - Street 1:119 TRUXTON AVE
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-2460
Practice Address - Country:US
Practice Address - Phone:850-862-4313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-23
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 50906174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist