Provider Demographics
NPI:1609148360
Name:LEARY, MARY NEWMAN (RN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:NEWMAN
Last Name:LEARY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1216 SUMTER LANDING LN
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-5502
Mailing Address - Country:US
Mailing Address - Phone:706-691-6567
Mailing Address - Fax:
Practice Address - Street 1:2260 WRIGHTSBORO RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-4764
Practice Address - Country:US
Practice Address - Phone:706-481-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-27
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN167967367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered