Provider Demographics
NPI:1619393956
Name:DE YOUNG, MARY J
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:J
Last Name:DE YOUNG
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:PO BOX 10700
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81502-5517
Mailing Address - Country:US
Mailing Address - Phone:970-243-5437
Mailing Address - Fax:970-243-7792
Practice Address - Street 1:3150 N 12TH ST
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81506-2863
Practice Address - Country:US
Practice Address - Phone:970-243-5437
Practice Address - Fax:970-243-7792
Is Sole Proprietor?:No
Enumeration Date:2014-03-11
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA115968163WP0200X
COAPN.0991236-NP363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO10674268Medicaid
CO10674268Medicaid