Provider Demographics
NPI:1871679571
Name:DAZEY, MARY T (CNM)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:T
Last Name:DAZEY
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 NORTHSIDE DRIVE
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602
Mailing Address - Country:US
Mailing Address - Phone:229-241-2800
Mailing Address - Fax:229-241-0454
Practice Address - Street 1:220 NORTHSIDE DRIVE
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602
Practice Address - Country:US
Practice Address - Phone:229-241-2800
Practice Address - Fax:229-241-0454
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAR079997367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00534465DMedicaid
GA00534465DMedicaid
S18876Medicare UPIN