Provider Demographics
NPI:1134624976
Name:WIXSON, MARY E
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:WIXSON
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 1:223 ONTARIO AVE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13209-1134
Mailing Address - Country:US
Mailing Address - Phone:315-447-3373
Mailing Address - Fax:
Practice Address - Street 1:223 ONTARIO AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13209-1134
Practice Address - Country:US
Practice Address - Phone:315-447-3373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-26
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY639051163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool