Provider Demographics
NPI:1740455807
Name:DEHART, MARY ELLEN (RN)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELLEN
Last Name:DEHART
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MRS
Other - First Name:MARY
Other - Middle Name:ELLEN
Other - Last Name:HEAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:701 LENOX AVE
Mailing Address - Street 2:
Mailing Address - City:ONEIDA
Mailing Address - State:NY
Mailing Address - Zip Code:13421
Mailing Address - Country:US
Mailing Address - Phone:315-363-9281
Mailing Address - Fax:315-363-9286
Practice Address - Street 1:701 LENOX AVE
Practice Address - Street 2:
Practice Address - City:ONEIDA
Practice Address - State:NY
Practice Address - Zip Code:13421
Practice Address - Country:US
Practice Address - Phone:315-363-9281
Practice Address - Fax:315-363-9286
Is Sole Proprietor?:No
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY373000-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02200373000Medicaid