Provider Demographics
NPI:1659732600
Name:ENDAHL, MARY J (CNM)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:J
Last Name:ENDAHL
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:JOSEPHINE
Other - Last Name:TOOTHMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 9007
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22906-9007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2955 IVY RD STE 304
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-9353
Practice Address - Country:US
Practice Address - Phone:434-243-4570
Practice Address - Fax:434-295-5491
Is Sole Proprietor?:No
Enumeration Date:2016-03-17
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024173448207V00000X, 367A00000X
WAAP60753690367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2081868Medicaid