Provider Demographics
NPI:1679824916
Name:ROLLINS, MARY EVELYN
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:EVELYN
Last Name:ROLLINS
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 1:2304 JERSEY RIDGE RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52803-2378
Mailing Address - Country:US
Mailing Address - Phone:563-320-2089
Mailing Address - Fax:
Practice Address - Street 1:2304 JERSEY RIDGE RD
Practice Address - Street 2:SUITE 4
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52803-2378
Practice Address - Country:US
Practice Address - Phone:563-320-2089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-26
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA006688225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist