Provider Demographics
NPI:1396067740
Name:STEWART, MARY ELLEN (MS, ATC)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELLEN
Last Name:STEWART
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1975 SCENIC DR
Mailing Address - Street 2:
Mailing Address - City:FORTUNA
Mailing Address - State:CA
Mailing Address - Zip Code:95540-2216
Mailing Address - Country:US
Mailing Address - Phone:707-499-0377
Mailing Address - Fax:
Practice Address - Street 1:1975 SCENIC DR
Practice Address - Street 2:
Practice Address - City:FORTUNA
Practice Address - State:CA
Practice Address - Zip Code:95540-2216
Practice Address - Country:US
Practice Address - Phone:707-499-0377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-25
Last Update Date:2024-05-13
Deactivation Date:2022-09-07
Deactivation Code:
Reactivation Date:2024-05-07
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer