Provider Demographics
NPI:1780083709
Name:GAVAGAN, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:GAVAGAN
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 1:3173 MAC AVE
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48506-2123
Mailing Address - Country:US
Mailing Address - Phone:810-397-0050
Mailing Address - Fax:
Practice Address - Street 1:3173 MAC AVE
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48506-2123
Practice Address - Country:US
Practice Address - Phone:810-397-0050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-14
Last Update Date:2014-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703033666164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse