Provider Demographics
NPI:1245826692
Name:REGIS, MARYLANDE
Entity type:Individual
Prefix:
First Name:MARYLANDE
Middle Name:
Last Name:REGIS
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 1:401 GLENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:EAST LANSDOWNE
Mailing Address - State:PA
Mailing Address - Zip Code:19050-2512
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 GLENWOOD AVE
Practice Address - Street 2:
Practice Address - City:EAST LANSDOWNE
Practice Address - State:PA
Practice Address - Zip Code:19050-2512
Practice Address - Country:US
Practice Address - Phone:267-235-5089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-18
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC257498163W00000X
PARN703181163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty