Provider Demographics
NPI:1396987608
Name:ERNST, MARY-ALICE RODSTROM (ANP)
Entity type:Individual
Prefix:MS
First Name:MARY-ALICE
Middle Name:RODSTROM
Last Name:ERNST
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:MARY-ALICE
Other - Middle Name:
Other - Last Name:RODSTROM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ANP
Mailing Address - Street 1:1232 UNIVERSITY OF OREGON
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97403-1205
Mailing Address - Country:US
Mailing Address - Phone:541-346-2770
Mailing Address - Fax:541-346-2747
Practice Address - Street 1:1590 E. 13TH ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97403-1232
Practice Address - Country:US
Practice Address - Phone:541-346-2770
Practice Address - Fax:541-346-2747
Is Sole Proprietor?:No
Enumeration Date:2009-04-01
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH333339163W00000X
KY1119712163W00000X
OH10367363LA2200X
OH333339-COA1363LA2200X
OR201050211NP363LA2200X
KY6004P363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000019886QOtherHUMANA
KY000000624383OtherANTHEM
KY1271256Medicare PIN
KY000019886QOtherHUMANA