Provider Demographics
NPI:1043420342
Name:PRINCE-PAUL, MARYJO (APRN PHD)
Entity Type:Individual
Prefix:
First Name:MARYJO
Middle Name:
Last Name:PRINCE-PAUL
Suffix:
Gender:F
Credentials:APRN PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E 185TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44119-1330
Mailing Address - Country:US
Mailing Address - Phone:216-486-6183
Mailing Address - Fax:
Practice Address - Street 1:300 E 185TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44119-1330
Practice Address - Country:US
Practice Address - Phone:216-486-6183
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN231816163WH1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH1000XNursing Service ProvidersRegistered NurseHospice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP90306Medicare UPIN