Provider Demographics
NPI:1649314840
Name:SOMERVILLE, MARY JONES
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:JONES
Last Name:SOMERVILLE
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 1:686 AXTELL RIDGEWAY RD
Mailing Address - Street 2:
Mailing Address - City:NORLINA
Mailing Address - State:NC
Mailing Address - Zip Code:27563-9250
Mailing Address - Country:US
Mailing Address - Phone:252-456-4239
Mailing Address - Fax:252-456-3718
Practice Address - Street 1:303 W FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:NC
Practice Address - Zip Code:27589-1937
Practice Address - Country:US
Practice Address - Phone:252-257-4568
Practice Address - Fax:252-257-2388
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC715493376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7801382Medicaid