Provider Demographics
NPI:1780044917
Name:LAUDERDALE, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:LAUDERDALE
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 1:1313 RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-4352
Mailing Address - Country:US
Mailing Address - Phone:970-493-1292
Mailing Address - Fax:970-493-1210
Practice Address - Street 1:1313 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524-4352
Practice Address - Country:US
Practice Address - Phone:970-493-1292
Practice Address - Fax:970-493-1210
Is Sole Proprietor?:No
Enumeration Date:2016-03-01
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO117108163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse