Provider Demographics
NPI:1689769093
Name:GANO, MARY KATHRYN (RN)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:KATHRYN
Last Name:GANO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 NORTH COUNTY LINE HWY
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:49238
Mailing Address - Country:US
Mailing Address - Phone:517-447-4053
Mailing Address - Fax:
Practice Address - Street 1:345 NORTH COUNTY LINE HWY
Practice Address - Street 2:
Practice Address - City:DEERFIELD
Practice Address - State:MI
Practice Address - Zip Code:49238
Practice Address - Country:US
Practice Address - Phone:517-447-4053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI47-04-198423163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4882886Medicaid