Provider Demographics
NPI:1487058319
Name:SOUTHARD, MARY ELAINE
Entity type:Individual
Prefix:MS
First Name:MARY ELAINE
Middle Name:
Last Name:SOUTHARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 S WEBSTER AVE.
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18505
Mailing Address - Country:US
Mailing Address - Phone:570-604-2994
Mailing Address - Fax:570-347-7604
Practice Address - Street 1:2222 WEBSTER AVE.
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18505
Practice Address - Country:US
Practice Address - Phone:570-604-2994
Practice Address - Fax:570-647-7604
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-21
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN2205411163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse