Provider Demographics
NPI:1568466373
Name:ADLER, MARY C (CERT PED NURSE PRACT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:ADLER
Suffix:
Gender:F
Credentials:CERT PED NURSE PRACT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:529 COFFMAN ST
Mailing Address - Street 2:STE 200
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-5450
Mailing Address - Country:US
Mailing Address - Phone:303-678-6137
Mailing Address - Fax:303-678-6125
Practice Address - Street 1:529 COFFMAN ST
Practice Address - Street 2:STE 200
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-5450
Practice Address - Country:US
Practice Address - Phone:303-678-6137
Practice Address - Fax:303-678-6125
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO49115363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07026354Medicaid