Provider Demographics
NPI:1972969558
Name:WELLER, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:WELLER
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 1:4240 MYSTERY CT
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89436-7178
Mailing Address - Country:US
Mailing Address - Phone:775-848-8745
Mailing Address - Fax:
Practice Address - Street 1:2 KEEWAYDIN DR
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:NH
Practice Address - Zip Code:03079-2839
Practice Address - Country:US
Practice Address - Phone:505-863-9551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-12
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVLPN07160164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse