Provider Demographics
NPI:1629167580
Name:FLY, MARY GUMP (ACNP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:GUMP
Last Name:FLY
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1231 GLENN AVE
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-4615
Mailing Address - Country:US
Mailing Address - Phone:706-736-1731
Mailing Address - Fax:
Practice Address - Street 1:1127 DRUID PARK AVE
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-5849
Practice Address - Country:US
Practice Address - Phone:706-364-6485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN163789363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care