Provider Demographics
NPI:1740067818
Name:MEJIA, MARY ELISABETH
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELISABETH
Last Name:MEJIA
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 1:12729 TANNENCREST DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33579-9415
Mailing Address - Country:US
Mailing Address - Phone:727-645-1955
Mailing Address - Fax:
Practice Address - Street 1:12729 TANNENCREST DR
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33579-9415
Practice Address - Country:US
Practice Address - Phone:727-645-1955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-12
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLM200-585-87-866-0172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver