Provider Demographics
NPI:1053952549
Name:AMMONS, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:AMMONS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:AMMONS
Other - Last Name:ODUNOLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:701 S 5TH ST APT C
Mailing Address - Street 2:
Mailing Address - City:GADSDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35901-5184
Mailing Address - Country:US
Mailing Address - Phone:256-390-6355
Mailing Address - Fax:
Practice Address - Street 1:7054 VETERANS PKWY
Practice Address - Street 2:
Practice Address - City:PELL CITY
Practice Address - State:AL
Practice Address - Zip Code:35125-5117
Practice Address - Country:US
Practice Address - Phone:205-227-7985
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-04
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2-064136164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse