Provider Demographics
NPI:1750147435
Name:TATE, MARY LOUISE (AGNP-C)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LOUISE
Last Name:TATE
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:434 PIERCE LN
Mailing Address - Street 2:
Mailing Address - City:MONTROSS
Mailing Address - State:VA
Mailing Address - Zip Code:22520-3121
Mailing Address - Country:US
Mailing Address - Phone:804-366-0913
Mailing Address - Fax:
Practice Address - Street 1:434 PIERCE LN
Practice Address - Street 2:
Practice Address - City:MONTROSS
Practice Address - State:VA
Practice Address - Zip Code:22520-2252
Practice Address - Country:US
Practice Address - Phone:804-366-0913
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-21
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024189538363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology