Provider Demographics
NPI:1639497803
Name:ST JOHN, MARY MARSTON (LAC, DIPOM)
Entity Type:Individual
Prefix:MS
First Name:MARY MARSTON
Middle Name:
Last Name:ST JOHN
Suffix:
Gender:F
Credentials:LAC, DIPOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10430 PARK RD
Mailing Address - Street 2:SUITE #200
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-8540
Mailing Address - Country:US
Mailing Address - Phone:704-541-7177
Mailing Address - Fax:
Practice Address - Street 1:10430 PARK RD
Practice Address - Street 2:SUITE #200
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-8540
Practice Address - Country:US
Practice Address - Phone:704-541-7177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-12
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC520171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist