Basic Information
| Provider Information | |||||||||
| NPI: | 1477131290 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARES | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | GRACE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3059 ANDERSON PL | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300331601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4049333826 | ||||||||
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| Practice Location | |||||||||
| Address1: | 141 CENTRE ST | ||||||||
| Address2: | |||||||||
| City: | ORANGEBURG | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291156043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8035347200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2021 | ||||||||
| LastUpdateDate: | 06/21/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN290035 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.