Provider Demographics
NPI:1831464593
Name:MANDERY, MARY BETH (RN)
Entity type:Individual
Prefix:
First Name:MARY BETH
Middle Name:
Last Name:MANDERY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:371 E FREDONIA DR
Mailing Address - Street 2:
Mailing Address - City:PUEBLO WEST
Mailing Address - State:CO
Mailing Address - Zip Code:81007-5318
Mailing Address - Country:US
Mailing Address - Phone:719-660-7387
Mailing Address - Fax:
Practice Address - Street 1:371 E FREDONIA DR
Practice Address - Street 2:
Practice Address - City:PUEBLO WEST
Practice Address - State:CO
Practice Address - Zip Code:81007-5318
Practice Address - Country:US
Practice Address - Phone:719-660-7387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-14
Last Update Date:2020-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO106119163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse