Provider Demographics
NPI:1841392974
Name:DEAL, MARY BLONDELL (APN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BLONDELL
Last Name:DEAL
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 PHYSICIANS DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-2071
Mailing Address - Country:US
Mailing Address - Phone:731-664-0103
Mailing Address - Fax:731-984-7272
Practice Address - Street 1:31 PHYSICIANS DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2071
Practice Address - Country:US
Practice Address - Phone:731-664-0103
Practice Address - Fax:731-984-7272
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN5466363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3900675Medicaid
TN39006731Medicaid
TN4162728OtherBCBS
TN41975OtherTLC
TN41975OtherTLC
TN39006731Medicare PIN
TN3900675Medicare PIN