Provider Demographics
NPI:1609116524
Name:DUPRIS, MARY JO (LPN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JO
Last Name:DUPRIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1784
Mailing Address - Street 2:
Mailing Address - City:EAGLE BUTTE
Mailing Address - State:SD
Mailing Address - Zip Code:57625-1784
Mailing Address - Country:US
Mailing Address - Phone:605-964-7224
Mailing Address - Fax:
Practice Address - Street 1:24276 166TH STREET AIRPORT ROAD
Practice Address - Street 2:
Practice Address - City:EAGLE BUTTE
Practice Address - State:SD
Practice Address - Zip Code:57625
Practice Address - Country:US
Practice Address - Phone:605-964-7724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-01
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDL-13883164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse