Provider Demographics
NPI:1922599802
Name:FORD, MARY JOHANNA
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JOHANNA
Last Name:FORD
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 1:17 E SIR FRANCIS DRAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:LARKSPUR
Mailing Address - State:CA
Mailing Address - Zip Code:94939-1727
Mailing Address - Country:US
Mailing Address - Phone:415-526-5631
Mailing Address - Fax:
Practice Address - Street 1:17 E SIR FRANCIS DRAKE BLVD
Practice Address - Street 2:
Practice Address - City:LARKSPUR
Practice Address - State:CA
Practice Address - Zip Code:94939-1727
Practice Address - Country:US
Practice Address - Phone:415-526-5631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-25
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95004594363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily