Provider Demographics
NPI:1730494428
Name:GERLACH, MARY A (CNS)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:GERLACH
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49641 REGATTA ST
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48047-2363
Mailing Address - Country:US
Mailing Address - Phone:586-725-0969
Mailing Address - Fax:586-203-1060
Practice Address - Street 1:49641 REGATTA ST
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MI
Practice Address - Zip Code:48047-2363
Practice Address - Country:US
Practice Address - Phone:586-725-0969
Practice Address - Fax:586-203-1060
Is Sole Proprietor?:No
Enumeration Date:2010-08-18
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704126749163W00000X
MI199934367163WX1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WX1500XNursing Service ProvidersRegistered NurseOstomy Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0319227OtherAMERICAN NURSES CREDENTIALING CENTER, CNS
MI199934367OtherWOCN