Provider Demographics
NPI:1861020372
Name:LEGLISE, MARY ANN
Entity Type:Individual
Prefix:
First Name:MARY ANN
Middle Name:
Last Name:LEGLISE
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 1:5784 GOLDEN EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89523-2046
Mailing Address - Country:US
Mailing Address - Phone:775-233-9399
Mailing Address - Fax:
Practice Address - Street 1:480 GALLETTI WAY BLDG 8N
Practice Address - Street 2:
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89431-5564
Practice Address - Country:US
Practice Address - Phone:775-688-1633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-30
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVRN53304163WP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent