Basic Information
| Provider Information | |||||||||
| NPI: | 1053952549 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AMMONS | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | ODUNOLA | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | AMMONS | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 701 S 5TH ST APT C | ||||||||
| Address2: | |||||||||
| City: | GADSDEN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 359015184 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2563906355 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7054 VETERANS PKWY | ||||||||
| Address2: | |||||||||
| City: | PELL CITY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 351255117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2052277985 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2019 | ||||||||
| LastUpdateDate: | 10/04/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 2-064136 | AL | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.