Provider Demographics
NPI:1861203879
Name:SMITH, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SMITH
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 1:303 1ST AVE NW # NWW
Mailing Address - Street 2:
Mailing Address - City:MOHALL
Mailing Address - State:ND
Mailing Address - Zip Code:58761-4215
Mailing Address - Country:US
Mailing Address - Phone:503-891-7958
Mailing Address - Fax:
Practice Address - Street 1:303 1ST AVE NW # NWW
Practice Address - Street 2:
Practice Address - City:MOHALL
Practice Address - State:ND
Practice Address - Zip Code:58761-4215
Practice Address - Country:US
Practice Address - Phone:503-891-7958
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-17
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health