Provider Demographics
NPI:1487698593
Name:SUMMERSON, MARY I (CRNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:I
Last Name:SUMMERSON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 PLUMBER ST
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:PA
Mailing Address - Zip Code:16365-1202
Mailing Address - Country:US
Mailing Address - Phone:814-723-2323
Mailing Address - Fax:814-726-3337
Practice Address - Street 1:14 PLUMBER ST
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:PA
Practice Address - Zip Code:16365-1202
Practice Address - Country:US
Practice Address - Phone:814-723-2323
Practice Address - Fax:814-726-3337
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP008969363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA00027486901OtherUNIVERA HEALTHCARE
PA00027486901OtherUNIVERA HEALTHCARE
PA100212HXYMedicare ID - Type Unspecified