Provider Demographics
NPI:1295962595
Name:CLYDE, MARY L (LPN)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:L
Last Name:CLYDE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:THAYER
Other - Last Name:CLYDE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:29 CRANE ST
Mailing Address - Street 2:
Mailing Address - City:CLIFTON SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:14432-1061
Mailing Address - Country:US
Mailing Address - Phone:315-462-7221
Mailing Address - Fax:
Practice Address - Street 1:29 CRANE ST
Practice Address - Street 2:
Practice Address - City:CLIFTON SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:14432-1061
Practice Address - Country:US
Practice Address - Phone:315-462-7221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-15
Last Update Date:2009-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY143853-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse