Provider Demographics
NPI:1518632124
Name:FORD, MARY (PMHNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:FORD
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 W PARK ST STE 420
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03766-1322
Mailing Address - Country:US
Mailing Address - Phone:603-667-6743
Mailing Address - Fax:866-309-2937
Practice Address - Street 1:20 W PARK ST STE 420
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03766-1322
Practice Address - Country:US
Practice Address - Phone:603-667-6743
Practice Address - Fax:866-309-2937
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-16
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH084024-23363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health