Provider Demographics
NPI:1285100073
Name:RHODES, MARY JO MALLORY (LPN)
Entity type:Individual
Prefix:MRS
First Name:MARY JO
Middle Name:MALLORY
Last Name:RHODES
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:359 LOWER MIDDLE RD
Mailing Address - Street 2:
Mailing Address - City:MILLPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14864-9785
Mailing Address - Country:US
Mailing Address - Phone:607-731-7495
Mailing Address - Fax:
Practice Address - Street 1:359 LOWER MIDDLE RD
Practice Address - Street 2:
Practice Address - City:MILLPORT
Practice Address - State:NY
Practice Address - Zip Code:14864-9785
Practice Address - Country:US
Practice Address - Phone:607-731-7495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-18
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY242052164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse