Provider Demographics
NPI:1790186880
Name:PAULSON, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:PAULSON
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 1:11260 E FLECK RD
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48877-9513
Mailing Address - Country:US
Mailing Address - Phone:989-763-7568
Mailing Address - Fax:
Practice Address - Street 1:11260 E FLECK RD
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:MI
Practice Address - Zip Code:48877-9513
Practice Address - Country:US
Practice Address - Phone:989-763-7568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-09
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703059762164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse