Provider Demographics
NPI:1508675166
Name:WARNER, MARY KATHLEEN
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHLEEN
Last Name:WARNER
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 1:4525 PIMLICO DR UNIT 203
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-2089
Mailing Address - Country:US
Mailing Address - Phone:219-241-3928
Mailing Address - Fax:
Practice Address - Street 1:4525 PIMLICO DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-2086
Practice Address - Country:US
Practice Address - Phone:219-241-3928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-07
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant