Basic Information
| Provider Information | |||||||||
| NPI: | 1740455807 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEHART | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ELLEN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HEAD | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | ELLEN | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 701 LENOX AVE | ||||||||
| Address2: | |||||||||
| City: | ONEIDA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153639281 | ||||||||
| FaxNumber: | 3153639286 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 LENOX AVE | ||||||||
| Address2: | |||||||||
| City: | ONEIDA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153639281 | ||||||||
| FaxNumber: | 3153639286 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2008 | ||||||||
| LastUpdateDate: | 04/29/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 373000-1 | NY | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 02200373000 | 05 | NY | MEDICAID |