Provider Demographics
NPI:1558815639
Name:DETMER, MARY ANN (LPN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:DETMER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 RUDOLPH WAY
Mailing Address - Street 2:
Mailing Address - City:GREENDALE
Mailing Address - State:IN
Mailing Address - Zip Code:47025-8312
Mailing Address - Country:US
Mailing Address - Phone:812-537-1668
Mailing Address - Fax:812-537-4078
Practice Address - Street 1:816 RUDOLPH WAY
Practice Address - Street 2:
Practice Address - City:GREENDALE
Practice Address - State:IN
Practice Address - Zip Code:47025-8312
Practice Address - Country:US
Practice Address - Phone:812-537-1668
Practice Address - Fax:812-537-4078
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-07
Last Update Date:2016-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN27033033A164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse