Provider Demographics
NPI:1558938175
Name:COMANCHE, MARY (RN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:COMANCHE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:ROBERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:3217 CONCORDIA AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-5131
Mailing Address - Country:US
Mailing Address - Phone:318-600-6323
Mailing Address - Fax:318-570-5153
Practice Address - Street 1:3217 CONCORDIA AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5131
Practice Address - Country:US
Practice Address - Phone:318-600-6323
Practice Address - Fax:318-570-5153
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-10
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA120619163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse