Provider Demographics
NPI:1265529721
Name:FOLLETT, MARY LOU (NP)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:LOU
Last Name:FOLLETT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2921 DOCTORS PARK DR
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8127
Mailing Address - Country:US
Mailing Address - Phone:541-245-4444
Mailing Address - Fax:541-973-2835
Practice Address - Street 1:3156 STATE ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8450
Practice Address - Country:US
Practice Address - Phone:541-773-9772
Practice Address - Fax:541-773-1113
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200250018NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR200250018NPOtherSTATE LICENSE
ORR78172Medicare UPIN
ORR115827Medicare ID - Type Unspecified