Provider Demographics
NPI:1588200356
Name:CRIDER, MARY CHRISTINE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CHRISTINE
Last Name:CRIDER
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 1:283 LOON LAKE DR
Mailing Address - Street 2:
Mailing Address - City:KYLE
Mailing Address - State:TX
Mailing Address - Zip Code:78640-5762
Mailing Address - Country:US
Mailing Address - Phone:512-395-7477
Mailing Address - Fax:
Practice Address - Street 1:283 LOON LAKE DR
Practice Address - Street 2:
Practice Address - City:KYLE
Practice Address - State:TX
Practice Address - Zip Code:78640-5762
Practice Address - Country:US
Practice Address - Phone:512-395-7477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-26
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX186928164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse