Provider Demographics
NPI:1912465063
Name:GRESHAM, MARY JANE
Entity Type:Individual
Prefix:
First Name:MARY JANE
Middle Name:
Last Name:GRESHAM
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 1:373 S WILLOW ST # 110
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03103-5751
Mailing Address - Country:US
Mailing Address - Phone:314-888-5233
Mailing Address - Fax:818-907-7828
Practice Address - Street 1:373 S WILLOW ST # 110
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03103-5751
Practice Address - Country:US
Practice Address - Phone:314-888-5233
Practice Address - Fax:818-907-7828
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-07
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174H00000XOther Service ProvidersHealth EducatorGroup - Single Specialty