Provider Demographics
NPI:1548333263
Name:RUNYAN, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:RUNYAN
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 1:4253 COVERED CREEK CT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32277-1444
Mailing Address - Country:US
Mailing Address - Phone:904-745-3934
Mailing Address - Fax:904-745-3234
Practice Address - Street 1:1309 SAINT JOHNS BLUFF RD N STE 101 BLDG B
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-8396
Practice Address - Country:US
Practice Address - Phone:904-745-1735
Practice Address - Fax:904-745-3234
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP 1394171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist