Provider Demographics
NPI:1699205476
Name:MABRY, MARCY DAWN
Entity Type:Individual
Prefix:
First Name:MARCY
Middle Name:DAWN
Last Name:MABRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARCY
Other - Middle Name:DAWN
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:230 N GREEN ST
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:KY
Mailing Address - Zip Code:42420-3109
Mailing Address - Country:US
Mailing Address - Phone:270-854-3196
Mailing Address - Fax:
Practice Address - Street 1:2955 FORT CAMPBELL BLVD
Practice Address - Street 2:
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240-4901
Practice Address - Country:US
Practice Address - Phone:270-985-3015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-14
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3011380363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty