Provider Demographics
NPI:1811209679
Name:FARRELL, MARY (CNM, WHNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:FARRELL
Suffix:
Gender:F
Credentials:CNM, WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1075 CAMINO DEL RIO S
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3538
Mailing Address - Country:US
Mailing Address - Phone:619-881-4500
Mailing Address - Fax:
Practice Address - Street 1:1075 CAMINO DEL RIO S
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3538
Practice Address - Country:US
Practice Address - Phone:619-881-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-09
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA682979163W00000X
CA19699363L00000X
CA1884367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner