Provider Demographics
NPI:1922033760
Name:OSBORNE, MARY ANN
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ANN
Last Name:OSBORNE
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:PO BOX 60099
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0099
Mailing Address - Country:US
Mailing Address - Phone:704-446-7800
Mailing Address - Fax:704-541-8727
Practice Address - Street 1:7810 PROVIDENCE RD
Practice Address - Street 2:SUITE 105
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-2954
Practice Address - Country:US
Practice Address - Phone:704-446-7800
Practice Address - Fax:704-541-8727
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC800035363LX0001X
NC54582363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7005107Medicaid
SCNP2828Medicaid
NC1922033760Medicaid
SCNP2828Medicaid
NC2805283Medicare PIN