Provider Demographics
NPI:1669924445
Name:JIMENEZ, MARY (LPN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:547 E CAMINO DE MANANA
Mailing Address - Street 2:
Mailing Address - City:HUACHUCA CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:85616-8137
Mailing Address - Country:US
Mailing Address - Phone:520-559-5705
Mailing Address - Fax:
Practice Address - Street 1:2240 WINROW AVE
Practice Address - Street 2:USA MEDDAC,RWBAHC
Practice Address - City:FORT HUACHUCA
Practice Address - State:AZ
Practice Address - Zip Code:85613
Practice Address - Country:US
Practice Address - Phone:520-533-9033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-27
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP034213164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse