Provider Demographics
NPI:1730927161
Name:ORTEGA, MARY GRACE DOROTHY ROLDAN
Entity type:Individual
Prefix:
First Name:MARY GRACE DOROTHY
Middle Name:ROLDAN
Last Name:ORTEGA
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 1:125 LEOPARD LN # 125
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND GAP
Mailing Address - State:TN
Mailing Address - Zip Code:37724-4458
Mailing Address - Country:US
Mailing Address - Phone:404-510-4902
Mailing Address - Fax:
Practice Address - Street 1:125 LEOPARD LN
Practice Address - Street 2:
Practice Address - City:CUMBERLAND GAP
Practice Address - State:TN
Practice Address - Zip Code:37724-4458
Practice Address - Country:US
Practice Address - Phone:404-510-4902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-18
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program