Provider Demographics
NPI:1790741775
Name:SHERIDAN, MARY (NNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SHERIDAN
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 DEMING DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25314-1013
Mailing Address - Country:US
Mailing Address - Phone:304-388-2238
Mailing Address - Fax:304-388-2618
Practice Address - Street 1:830 PENNSYLVANIA AVE
Practice Address - Street 2:SUITE 406
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302-3302
Practice Address - Country:US
Practice Address - Phone:304-388-2238
Practice Address - Fax:304-388-2618
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV43685363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal