Provider Demographics
NPI:1093314908
Name:PETERSON, MARY JANE (PROVIDER)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1126 MARIANNA DR
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44903-9672
Mailing Address - Country:US
Mailing Address - Phone:567-333-1298
Mailing Address - Fax:419-589-6641
Practice Address - Street 1:1126 MARIANNA DR
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44903-9672
Practice Address - Country:US
Practice Address - Phone:567-333-1298
Practice Address - Fax:419-589-6641
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-21
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2878275Medicaid